AGENDA for the MEETING of the COUNCIL of GOVERNORS 29 NOVEMBER 2018, 2.00PM – 4.00PM Holiday Inn, Scotch Corner, Darlington, D

AGENDA FOR THE MEETING OF THE COUNCIL OF GOVERNORS

29 NOVEMBER 2018, 2.00PM – 4.00PM Holiday Inn, Scotch Corner, Darlington, DL10 6NR

(Governor registration and hospitality available between 1pm and 1.45pm)

NOTE: Cllr Ann McCoy, Lead Governor will be available from 1pm to meet with Governors

Agenda: No What we will talk Why are we talking Lead Person Supporting about about this Paper / Spoken report 2.00pm – 2.15pm Standard Items 1. Welcome and For information Lesley Bessant, Spoken apologies for absence To make sure that Chairman we have enough Governors present to be quorate and introduce any new

attendees.

To advise of housekeeping arrangements

2. Minutes of the To agree Lesley Bessant, Attached meeting of the Council To check and Chairman of Governors held on approve the minutes 19 September 2018 of this meeting

3. Public Council of To discuss Lesley Bessant, Attached Governors’ Action Log To update on any Chairman action items

4. Declarations of To agree Lesley Bessant, Spoken Interest The opportunity for Chairman Governors to declare any interests with regard to any matter being discussed today

No What we will talk Why are we talking Lead Person Supporting about about this Paper / Spoken report 5. Chairman’s activities For information Lesley Bessant, Spoken To hear from the Chairman Chairman on what she has been doing

since the last meeting There will be an opportunity to ask any questions

6. Questions from To discuss Lesley Bessant, Spoken Governors Chairman To consider any questions raised by Governors which are not covered elsewhere on the agenda (Governors are asked to provide the Trust Secretary with at least 24 hours written notice if they wish to receive a formal answer to their questions at the meeting.)

1. Hazel Griffiths, Public Governor Harrogate and Wetherby

Can you provide some information on the role of the Freedom to Speak up Guardian for the Trust and the amount of contacts made.

Please see attached report for full response.

2. Sarah Talbot-Landon, Public Governor Durham

With great pride my family and I opened West Park’s new Child Friendly visiting suite in September 2018. Thank you so much to the Trust, for listening to my experiences and that of others and producing a safer child centred environment. Will the Trust commit to providing a similar model of suite in each of its hospitals?

Please see attached report for full response.

No What we will talk Why are we talking Lead Person Supporting about about this Paper / Spoken report

3. Cliff Allison, Public Governor Durham

a. What preparations is TEWV making for Brexit? In particular in terms of staff, which grades/types of staff would be most affected and how what is the position in relation to contracts for goods and services currently obtained from the Eurozone, are there contingency plans. In addition, are there any implications to the Trust’s assets?

b. Why is TEWV supplying Roseberry Park with French apples? There is a glut of apples in the UK just now which could be obtained cheaply and reduce our carbon footprint, as well as being a superior product and supporting our local growers.

Please see attached report for full response.

4. Christine Hodgson, Public Governor York

What services are available in the York area for Autism and ADHD. There appears to be a lack of provision in the area?

5. Cllr Ann McCoy, Appointed Governor Stockton Borough Council

(question raised at the meeting held on 16 May 2018 minute reference 18/40 refers)

After attending a Health and Wellbeing Children’s Partnership meeting a presentation was given on neurological paediatric brain damage and how some children are being misdiagnosed due to brain scans not being undertaken. How do we cope with this? Do we ask the appropriate question when someone is being diagnosed if there is brain damage? Children are usually judged against the performances of other children rather than asking family and friends. Can we see when we are diagnosing children if this is looked at as there was an example of a CAMHS child that had been in services for eight years? Please see attached report for full response.

No What we will talk Why are we talking Lead Person Supporting about about this Paper / Spoken report 6. Mary Booth, Public Governor Middlesbrough

Please see Appendix 1 to agenda for the full background and questions in relation to the Trust’s Care Quality Commission report following its inspection in 2018.

7. Tom McGuffog, Public Governor York

b. On Thursday October 18 I participated in a very well attended public meeting concerning the future of Bootham Park Hospital buildings and land. The session was chaired by Rachel Maskell MP and a number of key leaders spoke including the head of the Yorkshire and Humberside NHS STP (who said that he was very concerned at the overcrowded facilities at York Hospital and other NHS locations here).

All present agreed that Bootham Park land and buildings must be kept in use to support the needs of the community for physical and mental health services (including accommodation for nurses and other health professionals) plus recreation and sport - the grassland. These facilities must not be sold to the highest private bidder. They have served our needs since before the USA was founded.

Is there a TEWV view?

8. Della Cannings QPM, Public Governor Hambleton and Richmondshire

Thank you for the opportunity to attend the two day Mental Health First Aid course. The course materials prepared by MHFA England are excellent. It was a good opportunity for me as a Governor to meet with TEWV staff from a variety of specialisms. The course is clearly extremely helpful to individuals for themselves, within their private lives, as well as, being able to provide appropriate support and help to colleagues. The TEWV trainer was unable to

No What we will talk Why are we talking Lead Person Supporting about about this Paper / Spoken report answer my specific queries and so I said I'd direct them to yourselves for response.

It was unclear who the target candidates are for the course and particularly, it was unclear what was expected of the attendees once they returned to work. I was told there was nothing in place for employees to know which colleagues have received the training, or of how to contact them.

a. Could I please be advised of the answers to these queries

b. What are the future plans to build on the initial work already undertaken and to evaluate the benefits and value for money return?

c. Further, out of 16 expected attendees only 9 actually attended - what actions do the Trust take with regards to non-attendees and thus lost opportunities?

9. Keith Marsden, Public Governor Scarborough and Ryedale

Given the stress and anxiety caused to service users by changes in the benefits system, will the Trust look at ways in which we could provide more support and advice to assist people to stay well.

2.15pm – 2.20pm Governance Related Items 7. Summary of the For information Lesley Bessant, Attached discussions held at An opportunity to Chairman meetings of the Board read through the key of Directors areas discussed at recent meetings of the Board of Directors from September to October 2018 8. Constitutional Change For agreement Phil Bellas, Attached To consider a Trust Secretary proposed change to the Trust’s Constitution in relation to Staff Classes

No What we will talk Why are we talking Lead Person Supporting about about this Paper / Spoken report 2.20pm - 2.45pm Quality Related Items 9. Action Plans For information Phil Bellas, Attached To receive a Trust Secretary summary of the position of the action plans associated with the work of the Council of Governors

10. i. Compliance activity For information Jennifer in relation to the To receive a briefing Illingworth Attached Care Quality on the latest Director of Commission information from Quality Care Quality Governance ii. An update on any Commission items of relevance Inspections of the following contact Trust with the Care Quality Commission not contained in the report at i.

11. Service changes For information Ruth Hill Attached To receive a briefing Chief Operating on changes and Officer improvements to

services in the Trust

12. Quality Account For information Sharon Attached To receive an update Pickering, on the Trust’s draft Director of Quality Account for Planning, as at Q2 2018/19 Performance and Communications

No What we will talk Why are we talking Lead Person Supporting about about this Paper / Spoken report 2.45pm – 2.55pm Performance Related 13. The Trust’s For information Sharon Attached Performance To review the Pickering, Dashboard as at end performance of the Director of September 2018 Trust key indicators Planning, Performance and Communication

14. The Trust’s Finance For information Patrick Attached report as at end To receive McGahon, September 2018 information and Director of review the current Finance and financial position of Information the Trust

2.55pm – 3.05pm Standing Committees 15. Involvement and For information Cliff Allison, Spoken Engagement To receive Deputy, Committee information on the Chairman of work of this Committee committee and approve any recommendations made

16. Task and Finish For agreement Dr Hugh Griffiths, Attached Group: Involvement To receive the Non Executive findings and consider Director the recommendations made on the work of the task and finish group

No What we will talk Why are we talking Lead Person Supporting about about this Paper / Spoken report 3.05pm – 3.10pm Items for Information 17. Corporate Services For information David Levy Attached To receive a Director of summary of the Human functions undertaken Resources and within the Trusts’ Organisational Corporate Services Development

18. Equal Pay For information David Levy Attached To receive a report Director of on the Trust’s Human position in terms of Resources and equal pay Organisational Development

3.10 – 3.15pm Any Other Urgent Business 19. To raise any additional To discuss Lesley Bessant, Spoken matters of business To consider any Chairman other business matters raised by Governors which are not covered elsewhere on the agenda

(All business to be taken under this item must be approved by the Chairman. Governors must therefore give the Trust Secretary at least 24 hours written notice of any matters they wish to raise. No decisions shall be taken unless they are matters of urgency agreed by the Chairman)

No What we will talk Why are we talking Lead Person Supporting about about this Paper / Spoken report 3.15pm Procedural 20. Date and Time of next Spoken meeting:

14 February 2019, 2pm

Holiday Inn Scotch Corner Darlington

21. Confidential Motion

“That representatives of the press and other members of the public be excluded from the remainder of this meeting on the grounds that the nature of the business to be transacted may involve the likely disclosure of confidential information as defined in Annex 9 to the Constitution as explained below:

Information relating to a particular employee, former employee or applicant to become an employee of, or a particular office-holder, former office-holder or applicant to become an office- holder under, the Trust.

Any terms proposed or to be proposed by or to the Trust in the course of negotiations for a contract for the acquisition or disposal of property or the supply of goods or services.

Lesley Bessant Chairman Contact: Phil Bellas, Trust Secretary Tel. 01325 55 2001/Email: [email protected] 21 November 2018

Statement of values and behaviours

Commitment to quality

We demonstrate excellence in all of our activities to improve outcomes and experiences for users of our services, their carers and families and staff.

Behaviours: • Put service users first. • Seek and act on feedback from service users, carers and staff about their experiences. • Clarify people’s needs and expectations and strive to ensure they are exceeded. • Improve standards through training, experience, audit and evidence based practice. • Learn from mistakes when things go wrong and build upon successes. • Produce and share information that meets the needs of all individuals and their circumstances. • Do what you / we say we are going to do. • Strive to eliminate waste and minimise non-value adding activities.

Respect

We listen to and consider everyone’s views and contributions, maintaining respect at all times and treating others as we would expect to be treated ourselves.

Behaviours: • Be accessible, approachable and professional. • Consider the needs and views of others. • Be open and honest about how decisions are made. • Observe the confidential nature of information and circumstances as appropriate. • Be prepared to challenge discrimination and inappropriate behaviour. • Ask for feedback about how well views are being respected. • Consider the communication needs of others and provide a range of opportunities to access information.

Tees, Esk and Wear Valleys NHS Foundation Trust Values and Behaviours Involvement

We engage with staff, users of our services, their carers and families, governors, members, GPs and partner organisations so that they can contribute to decision making.

Behaviours: • Encourage people to share their ideas. • Engage people through effective consultation and communication. • Listen to what is said, be responsive and help people make choices. • Provide clear information and support to improve understanding. • Embrace involvement and the contribution that everyone can bring. • Acknowledge and promote mutual interests and the contributions that we can all make at as early a stage as possible. • Be clear about the rights and responsibilities of those involved.

Wellbeing

We promote and support the wellbeing of users of our services, their carers, families and staff.

Behaviours: • Demonstrate responsibility for our own, as well as others, wellbeing. • Demonstrate understanding of individual and collective needs. • Respond to needs in a timely and sensitive manner or direct to those who can help. • Be pro-active toward addressing wellbeing issues.

Teamwork

Team work is vital for us to meet the needs and exceed the expectations of people who use our services. This not only relates to teams within Tees, Esk and Wear Valleys NHS Foundation Trust, but also the way we work with GPs and partner organisations.

Behaviours: • Be clear about what needs to be achieved and take appropriate ownership. • Communicate well by being open, listening and sharing. • Consider the needs and views of others. • Be supportive to other members of the team. • Be helpful. • Fulfil one’s own responsibilities. • Always help the team and its members be successful.

Tees, Esk and Wear Valleys NHS Foundation Trust Values and Behaviours

Appendix 1

Item 6 supplementary information

Mary Booth, Public Governor Middlesbrough Background is included to each question to aid understanding and included at the request of Mary Booth.

a. Question area – 2018 Care Quality Commission (CQC) ratings

The recent CQC report highlighted some positives in the Trust with the email to Governors focussing on these. However, of the six services inspected in 2018 three received overall good ratings and three requires improvement. The 2018 inspected services that are good had maintained the rating from the previous inspection. Of the 2018 inspected services that need improvement one retained Requires Improvement (RI) and two had moved down one rating. While the Trust retained its overall rating of good this took into consideration the inspection in 2015 for 4 services which were rated at then as good and one in 2017 (May) rated then as good. The email to Governors did not highlight this.

It is of concern that the aggregated rating for the services inspected in 2018 had these been the only services the Trust provides or if we disregard the services which had the ratings from previous inspections (mainly) more than three years ago our overall rating would have been Requires Improvement. This is because when aggregating ratings, the CQC if the underlying requires improvement ratings are 4 to 8 the aggregated rating will normally be limited to requires improvement if 2 of the underlying ratings require improvement. https://www.cqc.org.uk/guidance-providers/nhs-trusts/ratings-principles-nhs-trusts

Clearly, we had six services inspected in 2018 and three of the underlying ratings required improvement.

How concerned is the Board that our current overall rating of Good is due to inspection ratings (mainly) over three years old? Taking into consideration that two of the ‘requires improvement’ services inspected in 2018 two had gone down from ‘Good’ to ‘Requires Improvement’ what is the Boards view on this?

Finally what action are the Board taking to maintain confidence in the ratings from 2015?

b. Question area - CQC care plans

One of the reasons for the 2018 CQC inspection rating Adult Mental Health Services and PICU as requires improvement is:

“Care plans were not always personalised, holistic or recovery-oriented. They contained generic statements, clinical terminology and did not reflect the patient’s voice.”

However, they also stated

“At Roseberry Park Hospital, care plans included detail of the preferences, views and thoughts of patients and often the patient’s own words. When patients were unwilling to engage in care planning with staff, they had a care plan focused on increasing their engagement and staff recorded their views”.

What action is the Board taking to roll out this good practice at Roseberry Park to other Adult Mental Health wards?

c. Question area - Activities v Occupational Therapy Provision

The recent CQC report identified some issues with the provision of activities in Adult Mental Health and PICU wards and also Forensic wards.

A general statement on activity for Adult Mental Health stated

“Activity provision on wards varied. On some wards, there was limited activity for patients when occupational therapy staff were not present. On other wards, nursing staff provided a range of activities throughout the week including weekends”.

They also stated

“At Roseberry Park Hospital, patients had access to dedicated facilities on an Activity Street. Occupational therapy staff created a welcoming environment and offered a range of activities during the week.”

And that

“Cedar ward Adult Mental Health at West Park Hospital had very limited occupational therapy and psychology input and these disciplines rarely attended report outs. This meant that nursing staff may not have identified all possible opportunities for intervention to meet patient needs”

In addition, it was identified that for Forensic Services

“There were no activity schedules or therapeutic activities taking place on the weekend on the majority of the wards, which goes against National Institute for Health and Care Excellence Guidance.”

I was pleased to see that in Adult Mental Health on some wards nursing staff are providing a range of activities across the week and at weekends. While Occupational Therapists use activity for both assessment and intervention this is part of therapy and they should not be considered the main providers of activity.

What action is the Board taking to identify the wards where nursing staff are providing activities throughout the week and weekend and rolling this good practice out.? This applies in both Adult Mental Health and Forensic services?

What action is the board taking to ensure all service managers and ward managers understand the difference between Occupational Therapy and the provision of ward- based activities across the week?

What action is being considered to provide Occupational Therapy and Psychology to Cedar ward in view of the comments in the report?

Again, please provide governors with whole statements above.

MINUTES OF THE COUNCIL OF GOVERNORS MEETING HELD ON 19 SEPTEMBER 2018, 6.00 PM AT HOLIDAY INN, SCOTCH CORNER, DARLINGTON

PRESENT: Lesley Bessant (Chairman) Gemma Birchwood (Selby) Mary Booth (Middlesbrough) Rachel Booth (Staff - Teesside) Della Cannings QPM (Hambleton and Richmondshire) Hilary Dixon (Harrogate and Wetherby) Mark Eltringham (Stockton on Tees) Gary Emerson (Stockton on Tees) Wendy Fleming-Smith (Selby) Chris Gibson (Harrogate and Wetherby) Glenda Goodwin (Staff - Forensic) Hazel Griffiths (Harrogate and Wetherby) Dr Judith Hurst (Staff - Corporate) Audrey Lax (Darlington) Cllr Ann McCoy (Appointed - Stockton Borough Council) Jacci McNulty (Durham) Keith Mollon (Durham) Jean Rayment (Hartlepool) Dr David Smart (Appointed - Clinical Commissioning Groups representative) Cllr Helen Swiers (Appointed - North Yorkshire County Council)

IN ATTENDANCE: Colin Martin (Chief Executive) Phil Bellas (Trust Secretary) Angela Grant (Administrator) Dr Hugh Griffiths (Non Executive Director) Marcus Hawthorn (Non Executive Director) David Jennings (Non Executive Director) Wendy Johnson (Secretary) Elizabeth Moody (Director of Nursing and Governance) Sharon Pickering (Director of Planning, Performance and Communications) Paul Murphy (Non Executive Director) Donna Oliver (Deputy Trust Secretary - Corporate) Kathryn Ord (Deputy Trust Secretary – Involvement and Engagement) Shirley Richardson (Non Executive Director) Richard Simpson (Non Executive Director) David Levy (Director of Human Resources and Organisational Development) Patrick McGahon (Director of Finance and Information)

18/65 APOLOGIES Lee Alexander (Appointed - Durham County Council) Cliff Allison (Durham) Phil Boyes (Staff - Durham and Darlington)

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Elizabeth Forbes-Browne (Scarborough and Ryedale) Stella Davison (York) Marion Grieves (Appointed - Teesside University) Sandra Grundy (Durham) Ian Hamilton (Appointed - University of York) Christine Hodgson (York) Kevin Kelly (Appointed - Darlington Borough Council) Dr Ahmad Khouja (Medical Director) Prof Hamish McAllister Williams (Appointed – Newcastle University) Prof Tom McGuffog MBE (York) Lisa Pope (Clinical Commissioning Groups representative) Gillian Restall (Stockton on Tees) Graham Robinson (Durham) Zoe Sherry (Hartlepool) Sarah Talbot-Landon (Durham) Cllr Stephen Thomas (Appointed – Hartlepool Borough Council) Ailsa Todd (Hambleton & Richmondshire) Prof Graham Towl (Appointed - Durham University) Judith Webster (Scarborough & Ryedale) Vanessa Wildon (Redcar and Cleveland) Alan Williams (Redcar and Cleveland) Mac Williams JP (Durham)

18/66 WELCOME

The Chairman opened the meeting and noted apologies.

18/67 MINUTES OF PREVIOUS MEETINGS

The Council of Governors considered the minutes from the public meeting held on 16 May 2018 and the Annual General and Members meeting on 18 July 2018.

Agreed 1. That the public minutes of the meeting held on 16 May 2018 be approved as a correct record and signed by the Chairman subject to the removal of the reference of Gemma Benson in the attendance list. 2. That the minutes of the Annual General and Members meeting be approved as a correct record and signed by the Chairman.

18/68 PUBLIC ACTION LOG

Consideration was given to the public action log.

Arising from the report:

1) Minute 18/08 – Governor access to Trust systems including email, e-learning and to consider the provision of IT equipment

It was noted that this would be carried forward until November 2018 to allow the piloting of a workbook on Equality, Diversity and Human Rights and a review of

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an online course for Safeguarding Adults. Investigations would also continue in relation to the access of Trust systems.

Ms D Cannings QPM offered to pilot the Equality, Diversity and Human Rights workbook. Action - Carried forward

3) Minute 18/19 – Speakers at future Governor Development Days

Agreement to defer until meetings in 2019 due to agenda availability. Action - Carried forward

4) Minute 18/40 – Neurological paediatric brain damage

Update not available. Action - Carried forward 5) Minute 18/46 – Corporate Services

David Levy advised that there were no significant changes to Corporate Services. He suggested that it might be helpful for an update to be submitted to the next meeting to summarise the functions provided by what Corporate Service departments. Action - Closed Action - David Levy

6) Minute 18/50 – Self Assessment of Council of Governors

Update not available. Action - Carried forward

18/69 DECLARATIONS OF INTEREST

There were no declarations of interest.

18/70 REGISTER OF INTERESTS

The Council of Governors received and noted the Register of Interests of Governors as at September 2018.

The Chairman requested that any further amendments be submitted by Friday 21 September 2018 as the register would then be made public.

Agreed - That the Council of Governors’ Register of Interests be updated with further declarations received and uploaded to the Trust website after 21 September 2018. Action - Mrs Ord

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18/71 STAFF RECRUITMENT

The Council of Governors considered the briefing update that had been submitted by Mr P Boyes, Staff Governor representing Durham and Darlington.

There were no issues raised.

Agreed – The Council of Governors received and noted the content of the briefing from Mr P Boyes.

18/72 ITEMS CIRCULATED FOR INFORMATION

As the agenda for the meeting had been truncated to enable a workshop to be held on the Trust’s business plan priorities, the Chairman requested that any questions on the reports circulated for information be sent to Mrs Ord for responses outside of the meeting.

Agreed – The Council of Governors received and noted the content of:

1) The questions submitted by Governors for which responses from the Board of Directors had been provided.

2) The Board of Directors feedback from the meetings held during April 2018 to July 2018.

3) The update in relation to compliance with Care Quality Commission requirements.

4) The update on the operational services provided by the Trust.

5) The position of the Trust’s Quality Account at the end of Quarter 1 2018/19.

6) The position as at end July 2018 of the Trust’s Performance.

7) The position as at the end of July 2018 of the financial position of the Trust.

18/73 FUTURE MEETINGS

The meetings in 2019 were agreed as:

 Thursday, 14 February 2019, 2pm

 Wednesday, 22 May 2019, 6pm

 Wednesday, 10 July 2019 6pm (special meeting if required)

 Wednesday, 17 July 2019, 6pm (Annual General and Members Meeting)

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 Wednesday, 18 September 2019, 6pm

 Thursday, 21 November 2019, 2pm

Venues were to be confirmed for these meetings.

The Chairman confirmed that a special meeting of the Council of Governors would be held if required on Thursday 27 September, 5.30pm at West Park Hospital, Darlington.

The next ordinary meeting would be held on 29 November 2018 at 2pm at Holiday Inn Scotch Corner, Darlington, DL10 6NR.

18/74 CONFIDENTIAL RESOLUTION

Confidential Motion “That representatives of the press and other members of the public be excluded from the remainder of this meeting on the grounds that the nature of the business to be transacted may involve the likely disclosure of confidential information as defined in Annex 9 to the Constitution as explained below:

Any terms proposed or to be proposed by or to the Trust in the course of negotiations for a contract for the acquisition or disposal of property or the supply of goods or services.

The Chairman closed the public session of the meeting at 6.05pm.

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ITEM NO. 3

COUNCIL OF GOVERNORS

DATE: 29 November 2018

TITLE: Public Action Log

REPORT OF: Phil Bellas, Trust Secretary REPORT FOR: Assurance

This report supports the achievement of the following Strategic Goals:  To provide excellent services working with the individual users of our services  and their families to promote recovery and wellbeing To continuously improve the quality and value of our work  To recruit, develop and retain a skilled, compassionate and motivated  workforce To have effective partnerships with local, national and international  organisations for the benefit of the communities we serve To be recognised as an excellent and well governed Foundation Trust that  makes best use of its resources for the benefit of the communities we serve.

Executive Summary: This report allows the Council of Governors to track progress on agreed actions.

Recommendations:

The Council of Governors is asked to received and note this report

Ref. KO 1 Date: 8 11 18 Council of Governors Action Log Item 3

RAG Ratings: Action completed/Approval of documentation Action due/Matter due for consideration at the meeting. Action outstanding but no timescale set by the Council. Action outstanding and the timescale set by the Council having passed. Action superseded Date for completion of action not yet reached

Date Minute No. Action Owner(s) Timescale Status To respond to the request to allow Governors to access February 18 Pilots have been undertaken various Trust systems including, email e-learning and the May 18 for EDHR and Safeguarding consider the provision of IT equipment. Kathryn Ord / September 18 trianing. This has been 25/01/2018 18/08 Drew Kendall November 18 succesful and will be rolled out to all Governors in due course To invite the Freedom to Speak Up Guardian and the Guardian May 18 of Safe working to a future Governor Development Day. October 18 Deferred due to availability of 22/02/2018 18/19 Kathryn Ord 2019 meeting staff and the priority of schedule agenda schedule

To provide a response to Cllr McCoy on her question relation David Brown June 2018 Response provided and 16/05/2018 18/40 to neurological paediatric brain damage. Ruth Hill November 2018 included within agenda To lead the establishment of a task and finish group to review 16/05/2018 18/50 the lower scoring areas of the Council's self assessment Cllr Ann McCoy

To provide a summary of the services that fall under the 19/09/2018 18/68 classification of Corporate Services David Levy November 2018 To upload the register of interests of Governors to the Trust's 24 September Completed 19/09/2018 18/70 Kathryn Ord website 2018

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ITEM NO. 6 FOR GENERAL RELEASE

COUNCIL OF GOVERNORS

DATE: 29 November 2018

TITLE: Council of Governors’ Questions – Summary of Responses

REPORT FOR: Information

COUNCIL OF GOVERNORS 29 NOVEMBER 2018

Responses to Governor Questions

1. Hazel Griffiths, Public Governor Harrogate and Wetherby

Can you provide some information on the role of the Freedom to Speak up Guardian for the Trust and the amount of contacts made.

Following on from your request for information regarding the role and contact with the Freedom to Speak up Guardian please see below. Dewi Williams is appointed to this role in the Trust.

Dewi has advised me that in 2017 9 cases were raised, 3 were anonymous, 3 related to patient safety, and 4 bullying. For 2017/18 in Quarter 1 there had been 4 cases, 3 bullying 1 patient safety raised. Quarter 2 figures have not yet been released.

In terms of information about the role please see the extract from the staff intranet site below.

The role of freedom to speak up guardian was identified as an action for all Trust’s following a report by Sir Robert Francis into the culture of raising concerns in the NHS. Dewi supports staff who have raised concerns as well as delivering mandatory training to managers (band 7 and above) about how to appropriately handle any concerns that have been raised. He also works alongside the Trust board to help develop more ways to empower and encourage staff to raise their concerns.

Dewi has worked in the NHS for 40 years and explained why he thinks the role is important:

“Throughout my career in nursing, general and clinical management I’ve seen plenty of both good and not so good practice, as well as how it’s been managed and handled. Speaking up isn’t about blame; it’s about staff knowing who to contact with their concerns, no matter how big or small, and knowing these will be addressed both confidentially and fairly. We want to be in a position where we’re welcoming and thanking staff who raise a concern. The more we can strengthen a culture of openness, the more we can continuously improve patient safety and standards of care for the benefit of our patients and staff.”

How to raise a concern: If you have a concern about risk, malpractice, or wrong doing which you believe could harm the service we deliver we would encourage you to raise this with your line manager or senior manager as soon as possible. If you feel that you are unable to do this you can raise your concerns in a number of ways: • Contact Dewi Williams, freedom to speak up guardian • Raise your concern anonymously via inTouch (internal intranet system) • Call our anonymous phone line and leave a voicemail Tel. 01325 552267

Concerns could include things like: • unsafe patient care or working conditions • inadequate induction or training for staff • lack of, or poor response to a reported patient safety incident • suspicion of fraud, corruption, or bribery (which can also be reported to our local counter fraud team) • a bullying culture ( across a team rather than individual incidences of bullying) Information for managers • Please use this form (this is an internal link to form on staff intranet) to record your handling of concerns raised by members of your staff or team. • For further guidance on how to support staff who raise a concern, please refer to the Trust’s Whistleblowing policy

2. Sarah Talbot-Landon, Public Governor Durham

Will the Trust commit to providing a similar model of suite in each of its hospitals?

Thank you Sarah for your recent request for more information around child friendly visiting suite facilities. Where we have new facilities being built we are incorporating these facilities in our units. With other units we have done a quick summary of our facilities so you can see what is available (identified as visiting space or can be used to meet that need if required). In some cases we are limited by the space/ availability but staff do try and be flexible where possible but also manage the environment and safeguarding issues that we have to be aware of.

For the new York Hospital there will be a child visiting room on each of the 4 wards – all nearby but separate to the wards and all with safe outdoor space too. We are also looking at St John’s offer of recreation for children visiting the new hospital – sports groups etc if visiting is anxiety-provoking. This is still work in progress with the University and the Trust.

For the other Trust areas Estates have confirmed the following facilities that are available:

 Westwood have 2  Newberry have 2  Evergreen now use the Group Therapy Room as their initial room was changed to provide a Ward Managers Room  Ridgeway have 1 and there is 1 that Adult Services use near to the patients Bank in Dalesway.  One is planned for Lanchester Road but there is not one on that site at the moment.  Cross Lane Hospital has one outside of Ayckbourne Unit, the adult ward but not one in Rowan Lea which is the older persons unit.  Peppermill Court has 1.  Acomb Garth has a visitor room but not specifically identified just for children.  There are no specific facilities at Meadowfields or Cherrytrees but staff will locate rooms if required.  Auckland Park don’t have a specifically identified room but if required use the Activity Room.  Sandwell Park does not have a specific room outside of the ward or in it nor does Lustrum Vale but they do have rooms that are not specific that could be used.  Springwood doesn’t have a specific room either.

I hope this helps give you a better understanding of the space and use.

3. Cliff Allison, Public Governor Durham a. What preparations is TEWV making for Brexit? In particular in terms of staff, which grades/types of staff would be most affected and how what is the position in relation to contracts for goods and services currently obtained from the Eurozone, are there contingency plans. In addition, are there any implications to the Trust’s assets? b. Why is TEWV supplying Roseberry Park with French apples? There is a glut of apples in the UK just now which could be obtained cheaply and reduce our carbon footprint, as well as being a superior product and supporting our local growers.

Answer to a.

To be provided at the meeting on 29 November 2018

Answer to b.

The Trust utilises the NHS supply chain framework for its Fresh Food provision. The contract details for this are:

 Total Produce supplier  Contract start date: 01/06/2015  End date: 31/05/2019 https://www.supplychain.nhs.uk/product-news/contract-launch-briefs/contract- information/fresh-food/

Total Produce have confirmed that their fruit and vegetables are sourced from a variety of countries, she said the quality of fruit and veg is better from these countries due to the better weather conditions and the unpredictability of the British weather means that they can have supply issues.

There are a number of benefits to using the framework included on the link to supply the Trust with its fresh produce:

 Providing enhanced range and value from a single source.  More savings  Pay less - With NHS Supply Chain you have a wider range of product options so you can select the ones that are fit-for-purpose and offer value-for-money.  Spend less time and money on tendering and let our procurement specialists undertake it on your behalf.

 Back office savings - The efficiencies of our service, ranging from e-ordering to consolidated deliveries, enable significant back office savings.  More value  An integrated approach - The financial benefits of NHS Supply Chain go beyond just product prices. The approach is an integrated one that reduces cost throughout the supply chain, from raw materials to global logistics, resulting in a much lower total cost.  When there are changes in the market, a single approach can minimise the impact of price rises and give support with cost-saving initiatives  Knowledge and expertise with dedicated account managers  NHS Supply Chain Buyers - Procurement specialists in product fields who can give expert advice on new and alternative products.  Customer Services Team - With the daily support provided by our dedicated and knowledgeable advisors and service  Consultation Groups - We consult with our Consultation Groups and other relevant parties drawn from the NHS, so that we can be sure the products we are providing are fit for purpose in every way.  Dependable deliveries - Having access to the know-how and resources of one of the world’s largest logistics companies means we can offer unrivalled dependability and responsiveness when it comes to our delivery services.  Framework agreement awarded in accordance with European procurement legislation  Sustainable development - We are certified to ISO 140001 International Standard for Environment Management System.  Sustainable procurement - We are working to reduce our carbon emissions by 15%.  NHS Supply Chain is operated by DHL and acts as an agent of the NHS Business Services Authority (NHSBSA) in its procurement.

4. Christine Hodgson, Public Governor York

What services are available in the York area for Autism and ADHD. There appears to be a lack of provision in the area?

Answer to be provided at the meeting on 29 November 2018

5. Ann McCoy, Appointed Governor Stockton Borough Council (question raised at the meeting held on 16 May 2018 minute reference 18/40 refers)

Response provided by Ruth Hill, Chief Operating Officer The issue was considered by the CAMHS Service Development Group (which has service managers and clinical staff representing the services trust wide) and they have highlighted the following. If the referral has come from social work, school, GP, third sector then it is the same pathway as CAMHS: all initial assessments cover medical history, accidents, admissions to paediatrics etc with more specific questions if risk is related to neurodevelopmental or Learning Disability. If the referral has come from youth offending teams (YOTs) then the YOT have a specific question in their assessment plus that asks about TBI, so they would find out about it that way. We would consider Traumatic Brian Injury (TBI) if present as part of wider risk assessment: how TBI contributes to risk presentation. But would require neuropsych colleagues to carry out specific assessments to understand deficits and strengths if they are under neurologist. I hope this gives you some information on how brain injury is assessed through CAMHS. Kath Davies Senior Clinical Director would be happy to discuss any further queries you may have.

6. Mary Booth, Public Governor Middlesbrough

Background is included to each question to aid understanding and included at the request of Mary Booth. a. Question area – 2018 Care Quality Commission (CQC) ratings

Clearly, we had six services inspected in 2018 and three of the underlying ratings required improvement.

Finally what action are the Board taking to maintain confidence in the ratings from 2015? b. Question area - CQC care plans

One of the reasons for the 2018 CQC inspection rating Adult Mental Health Services and PICU as requires improvement is:

“Care plans were not always personalised, holistic or recovery-oriented. They contained generic statements, clinical terminology and did not reflect the patient’s voice.”

However, they also stated

What action is the Board taking to roll out this good practice at Roseberry Park to other Adult Mental Health wards? c. Question area - Activities v Occupational Therapy Provision

The recent CQC report identified some issues with the provision of activities in Adult Mental Health and PICU wards and also Forensic wards.

A general statement on activity for Adult Mental Health stated

They also stated

And that

In addition, it was identified that for Forensic Services

I was pleased to see that in Adult Mental Health on some wards nursing staff are providing a range of activities across the week and at weekends. While Occupational

Therapists use activity for both assessment and intervention this is part of therapy and they should not be considered the main providers of activity.

What action is the Board taking to identify the wards where nursing staff are providing activities throughout the week and weekend and rolling this good practice out? This applies in both Adult Mental Health and Forensic services?

What action is the board taking to ensure all service managers and ward managers understand the difference between Occupational Therapy and the provision of ward- based activities across the week?

What action is being considered to provide Occupational Therapy and Psychology to Cedar ward in view of the comments in the report?

Again, please provide governors with whole statements above.

A full briefing is to be provided to Governors on 29 November 2018 and a summary of the response to these questions provided at the meeting.

7. Tom McGuffog, Public Governor York

a. Which community facilities are the Trust operating in York and District. For example is Acomb Garth remaining open? Given the stated NHS mental health objective to have fewer patients occupying hospital beds and more people supported at home and in the community, what facilities will be in place? b. On Thursday October 18 I participated in a very well attended public meeting concerning the future of Bootham Park Hospital buildings and land. The session was chaired by Rachel Maskell MP and a number of key leaders spoke including the head of the Yorkshire and Humberside NHS STP (who said that he was very concerned at the overcrowded facilities at York Hospital and other NHS locations here).

Is there a TEWV view?

A response will be provided at the meeting on 29 November 2018

8. Della Cannings QPM, Public Governor Hambleton and Richmondshire

It was unclear where the course sits with regards to the Trust strategy with regards to the well-being and support to staff, and what the Trust action plan is with regards to maximising upon the training being given to staff as Mental Health First Aiders. a. Could I please be advised of the answers to these queries b. What are the future plans to build on the initial work already undertaken and to evaluate the benefits and value for money return? c. Further, out of 16 expected attendees only 9 actually attended - what actions do the Trust take with regards to non-attendees and thus lost opportunities?

A response will be provided at the meeting on 29 November 2018

9. Keith Marsden, Public Governor Scarborough and Ryedale

Given the stress and anxiety caused to service users by changes in the benefits system, will the Trust look at ways in which we could provide more support and advice to assist people to stay well.

A response will be provided at the meeting on 29 November 2018

ITEM NO. 6 FOR GENERAL RELEASE

COUNCIL OF GOVERNORS

DATE: 29 November 2018

TITLE: Council of Governors’ Questions Supplementary report for Summary of Responses

REPORT FOR: Information

COUNCIL OF GOVERNORS 29 NOVEMBER 2018

Responses to Governor Questions

Question 3.

Cliff Allison, Public Governor Durham a. What preparations is TEWV making for Brexit? In particular in terms of staff, which grades/types of staff would be most affected and how what is the position in relation to contracts for goods and services currently obtained from the Eurozone, are there contingency plans. In addition, are there any implications to the Trust’s assets?

A response will be provided at the meeting on 29 November 2018

Question 4.

Christine Hodgson, Public Governor York

What services are available in the York area for Autism and ADHD. There appears to be a lack of provision in the area?

Response

Following your meeting with Darren Gargan on 1 November I hope that you now have a better understanding of the services provided by the Trust in relation to Autism and ADHD provision for the York and Selby area.

Discussions have also been arranged with the Autism Project lead (Jacqui Dyson) for the Trust which I understand you are keen to work more closely with.

In terms of the position of the Trust we are not currently commissioned to provide Autism or ADHD specific services in the York & Selby locality, however we do routinely work with clients with Mental Health difficulties who also have Autism or ADHD. The Trust has committed to provide training for front-line staff for Autism.

In relation to the training, we hope to be able to provide you with some statistics around this at the meeting on 29th November.

Within York and Selby the Trust offer an ASC assessment service for children and young people from 5 – 18. Assessments for under 5s are undertaken by York Hospital. There is a waiting time for the assessment of approx. 60 weeks. Vale of York Clinical Commissioning Group (CCG) have recently committed money to fund a waiting list initiative to increase the number of assessments until the end of March 2019.

ADHD Assessments and ongoing treatment is offered within the service for 6 – 18 year olds. Currently the waiting time for assessment is approximately 45 weeks. If diagnosed, treatment may consist of on-going access to the Parent’s support group, medication and physical health monitoring and psychoeducation to schools regarding how best to support the child in school.

Question 6.

Mary Booth, Public Governor Middlesbrough

a. How concerned is the Board that our current overall rating of Good is due to inspection ratings (mainly) over three years old? Taking into consideration that two of the ‘requires improvement’ services inspected in 2018 two had gone down from ‘Good’ to Requires Improvement’ what is the Boards view on this? Finally, what action are the Board taking to maintain confidence in the ratings from 2015?

Response

The inspection framework used by the CQC to assess NHS Trusts means that not all core services are inspected every time that the Trust receives an inspection. This means that for all Trusts, new and previous ratings are both used to assign an overall rating when inspections occur.

The Trust is very happy to have retained the overall rating of good. However, it is disappointing that the CQC rated two services as ‘requires improvement’ during the recent inspection. This is a decision which was challenged by the Trust, however, the CQC did not undertake a ratings review and therefore no changes were made. A full action plan has been agreed and all services will be working on this to ensure that required improvements take place to ensure the recent ‘requires improvement’ ratings are improved in the next inspection. As part of the on-going Trust action plan and the preparations for the next inspection the Board will be seeking

assurance that the ratings for the core services which have remained unchanged since 2015 will, at the very least, be maintained.

b. What action is the Board taking to roll out this good practice at Roseberry Park to other Adult Mental Health Wards?

Response

The Adult Mental Health (AMH) services are working collaboratively to implement the agreed CQC action plan. This includes sharing learning and best practice between Localities via the AMH Service Development Group (SDG).

AMH services also attend the trust wide Quality Compliance Group to feedback on progress on the implementation of the CQC action plan and to share good practice with other Directorates and Specialties.

c. What action is the Board taking to identify the wards where nursing staff are providing activities throughout the week and weekend and rolling this good practice out? This applies in both Adult Mental Health and Forensic services?

Response

The services are working collaboratively to implement the agreed CQC action plan. This includes sharing learning and best practice between Localities via the Quality

Assurance Groups (QuAGs) and the Service Development Groups (SDG). These services also attend the trust wide Quality Compliance Group which is a further opportunity to share good practice examples with other Directorates and Specialties.

d. What action is the Board taking to ensure all service managers and ward managers understand the difference between Occupational Therapy and the provision of ward-based activities across the week?

Response

The Occupational Therapy (OT) leadership team continues to work with service and ward managers on an ongoing basis to help them understand the difference between governed therapy which is delivered by the OT team and uses activity and occupation as its tool for delivery and diversional activity which is generally therapeutic in nature as part of the basic ward care and engagement. This is an area that some ward managers can on occasion be unclear about.

Activity and engagement are part of a service user’s day and everyone’s business. OT staff are available to provide advice and support to staff where engaging service users in daily activities is proving difficult.

In addition, the Forensic Service Managers recently acknowledged that OT and diversional activities are separate entities and have requested a review of both of these over the next few months. The Professional Lead for OT is supporting this review.

The Director of Therapies is also monitoring this on Directors visits throughout the Trust and then feeding back to the Executive Management Team and the Professional Head for OT. e. What action is being considered to provide Occupational Therapy and Psychology to Cedar Ward in view of the comments in the report?

Response

Recruitment plans are in place to provide additional OT support and a new model using a centralised OT Hub is being established at West Park Hospital which will commence on the 3rd December 2018. The Hub will provide occupational therapy for all wards and will be an improved model of service which can cover staff annual leave and any sickness absence etc. The OT Team will attend a daily report out on wards to assess patient need in terms of OT input and provide intervention as required.

An Activity Co-ordinator role is also being recruited to at West Park Hospital. This will ensure that there are dedicated staff to support diversional activities for service users. The Activity Co-ordinator role is not an OT role but will be on the national OT career framework with the OT leadership structure supporting them.

The AMH Service has also recently recruited a part time Psychologist in order to provide psychology input into Cedar ward. Internal discussions are also taking place with the view to providing an additional two sessions of psychology each week. The Director of Therapies will monitor Psychology provision via existing performance metrics for governed psychological therapies and through Directors visits to individual clinical teams.

Question 7.

Tom McGuffog, Public Governor York a. Which community facilities are the Trust operating in York and District. For example is Acomb Garth remaining open? Given the stated NHS mental health objective to have fewer patients occupying hospital beds and more people supported at home and in the community, what facilities will be in place?

Response

In addition to inpatient services, community mental health services are currently operating from the following premises:

Acomb, York: Acomb Health Centre – Mental Health Services Older Persons Community Mental Health Team for York West Acomb Garth - Adult Mental Health Community Mental Health Team for York West*

Shipton Road, York Lime Trees– Children and Young Persons Community Mental Health Team for York

Clifton Moor, York Systems House, Clifton Moor, York – Learning Disabilities Community Team for York and Selby, including CYC Case Management Team for Learning Disabilities

Huntington House, East Community Hub, York Access and Wellbeing Team Improving Access to Psychological Therapies (IAPT) Team Early Intervention in Psychosis (EIP)Team Rehab and Recovery Community Team Assertive Outreach Team (AOT) Care Home and Dementia (CHAD) Team (will move to new hospital in April 2020). Memory Team Perinatal Team for York and Selby Dialectical Behavioural Therapy (DBT) Team Mental Health Services Older Persons Community Mental Health Team for York East Adult Mental Health Community Mental Health Team for York East

Peppermill Court, York: Adult Mental Health Crisis, Recovery and Home Treatment Team (will move to new hospital in April 2020). Adult Mental Health Street Triage Team

Fulford Road, York Mental Health Force Control Room Team (and link to Street Triage Services across North Yorkshire)

Clarence Street, York

Safe Haven Crisis Café ( provided under contract by Mental Health Matters)

Selby: Worsley Court, Selby - *Mental Health Services Older Persons Community Mental Health Team for York South and *Adult Mental Health Community Mental Health Team for York South Selby Memorial Hospital – Hot desking space and outpatient rooms for *Learning Disabilities Community Team in Selby The Cabins, Flaxley Road, Selby - *Children and Young Persons Community Mental Health Team for Selby

*The planned Selby Hub will incorporate all of these services under one roof and will enable us to more efficiently manage our resources and hence significantly improve access (and experience) for our service users and carers.

Additionally:

Community teams have use of space at Pocklington Health Centre to enable easy access for Pocklington residents.

Acomb Garth inpatient unit currently accommodates 14 male dementia beds. It has always been planned that these beds will move to the new hospital on Haxby Road when it opens in April 2020 and that the total number of dementia beds available in York will decrease by 10 beds, to 18 in total. This was discussed throughout the public consultation in October 2016 to January 2017 and confirmed in March 2017.

Work is also underway to transform our older persons community services, in order to meet increased demand and expectation and to support people at home, or their place of residence, wherever clinically appropriate. This work has included enhanced working hours for the CHAD team, the introduction of clear gatekeeping guidelines to prevent unnecessary admission (research dictates that these unnecessary admissions harm for patients) and exploration of how we might better align services to the communities we serve. An intended outcome of this work will be improved bed management and crisis response for older people.

Locally we have worked hard to transform services and enable improved access. Managing our services over such a large number of sites presents a number of challenges for us. Discussion is underway regarding the poor state of a number of premises and ideas are being discussed, including the consideration of the development of a West Hub in York. This could be a smaller hub than Huntington House but would allow us to vacate Acomb Health Centre, Acomb Garth and Lime Trees – we have insufficient space in these premises and want to improve the quality of building to improve service user experiences. This is in early stages of discussion and has not been decided at this stage. The opportunity to develop a West hub will need to be considered in the context of all Trustwide estates master planning options and capital affordability

Is there a TEWV view?

Response

Bootham Park Hospital is owned by NHS Property Services. The Trust vacated the property in October 2017, following a series of comprehensive discussions with local planners and with Historic England regarding the changes that would be required in order for the premises to be fit for our purposes (and CQC compliant) in delivering inpatient and community services. As a result of exhaustive appraisal work it was agreed by City of York Council planning team and Historic England that the building was not suitable for our needs without a significant level of redesign, including areas of demolition, and our future use was therefore ruled out whilst alternative development sites were available within the city.

The Trust does not have a view on future use of the Bootham Park Hospital site, but is fully aware of the local public consultation process that is currently underway.

Additionally key Trust staff, (Head of Capital Design and Strategic Project Manager) have provided important information to York Teaching Hospitals Trust regarding the limitations in relation to the recognised heritage aspects of the Bootham Park premises, in order to assist with their own options appraisal process.

Question 8.

Della Cannings QPM, Public Governor Hambleton and Richmondshire

Response

The course is open to any staff or governors who wish to participate.Provision of the Mental Health First Aid course is intended to complement other staff health and wellbeing activities and services within TEWV by helping participants to develop their confidence and communication skills to support colleagues and teams experiencing mental health challenge.

The training is being provided on a pilot basis at present. When the six month long pilot is completed an evaluation report is to be produced and shared with the Trust Health and Wellbeing Group. The evaluation will help to inform next steps and will include an evaluation of the return on investment.

Did Not Attend (DNA) numbers are monitored and those booked to participate are encouraged to provide notice of non-attendance as soon as possible. The reported reasons for DNAs are predominantly sickness absence and the prioritisation of urgent clinical/service need ahead of training attendance. No specific action is routinely taken in respect of individual employees who DNA unless there are good reasons for such action to be taken.

Question 9.

Keith Marsden, Public Governor Scarborough and Ryedale

Given the stress and anxiety caused to service users by changes in the benefits system, will the Trust look at ways in which we could provide more support and advice to assist people to stay well.

A response will be provided at the meeting on 29 November 2018

Question 10 (additional question and not contained on the published agenda).

Keith Mollon, Public Governor Durham

Over the last few weeks/ months the neighbours around the Primrose Lodge have indicated that residents have been smoking around the streets, sometime littering the pavement with cigarette ends.

The neighbours had a meeting with the management and staff at Primrose Lodge to try to come up with a solution to end this problem. The council did place a bin further up the street however it is felt that it’s not located in the best position, however the council cannot place it closer.

The management has purchased some E cigarettes for the residents but the neighbours feel as if that is not the solution. There was a meeting Tuesday 27th November at Primrose Lodge with the management and the neighbours and the neighbours are asking if the smoking ban could be lifted?

The management explained the Trust’s and NHS policy which was introduced in March 2016. The neighbours asked who was the person who can give the answer to re-install the smoking shelter also to offer them to attend Primrose Lodge to see their concerns. I agreed to raise this matter at the Council of Governors as a formal question to which meeting on Thursday afternoon and would ask the question and the reply to be minuted.

A response will be provided at the meeting on 29 November 2018

Question 11 (additional question and not contained on the published agenda).

Hazel Griffiths, Public Governor Harrogate and Wetherby

Can the Board of Directors provide clarification on the York and Selby And North Yorkshire amalgamation of management structure and community team structures and any other updates on the merger between these localities?

A response will be provided at the meeting on 29 November 2018

ITEM NO 7 FOR GENERAL RELEASE

COUNCIL OF GOVERNORS

DATE: 29 November 2018 TITLE: Board round-up REPORT OF: Phil Bellas REPORT FOR: Assurance/Informmation

This report supports the achievement of the following Strategic Goaals:  To provide excellent services working with the inndividual users of our services and their families to promote recovery and wellbeing To continuously improve the quality and value of our work To recruit, develop and retain a skilled, compassionate and motivateed workforce To have effective partnerships with local, national and international organisations for the benefit of the communities we serve To be recognised as an excellent and well governed Foundation Trust that  makes best use of its resources for the benefit of the communities we serve.

Executtive Summary:

This report allows the Council of Governors to note the summary of discussions that took place at recent meetings of the Board of Directors.

Recommendations:

The Council of Governors is asked to receive and note this report.

Ref. KO 1 Date: 23 10 18

MEETING OF: COUNCIL OF GOVERNORS

DATE: 29 November 2018

TITLE: Board round-up

1. INTRODUCTION & PURPOSE:

1.1 The purpose of this report is to provide the Council of Governors with an update on the matters consideered by the Board of Directors.

2. BACKGROUND INFORMATION AND CONTEXT:

2.1 The Council of Governors approved the recommendations off its Task and Finish Group on “Holding the Non Executive Directors to Acccount for the Performance of the Board” at its meeting held on 24th September 2014 (minute 14/70 refers).

2.2 Under recommendation 2 of the review report it was proposeed that copies of the Board round-up (a brief summary of key issues which is produced by the Communications Department following each Board meeting and published on the intranet) should be presented to the Council of Governors, as an aide memoire, to assist Governors, and others attending the Board meetings, to highlight any business related matters which they consider important to bring to the attention of the Council of Governors.

3. KEY ISSUES:

3.1 Copies of the Board round-ups for the meetings held in September and October are attached to this report.

4. IMPLICATIONS:

4.1 Compliance with the CQC Fundamental Standards: No risks have been identified.

4.2 Financial/Value for Money: No risks have been identified.

4.3 Legal and Constitutional (including the NHS Constitution): No risks have been identified

4.4 Equality and Diversity: No risks have been identified.

4.4 Other implications: No risks have been identified

5. CONCLUSIONS:

5.1 This report is presented to the Council of Governors in accorddance with the action plan developed to implement the recommendations of the Task and

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Finish group on “Holding the Non Executive Directors to Account for the Performance of the Board”.

6. RECOMMENDATIONS:

6.1 The Council of Governors is asked to note the key matters considered by the Board of Directors at its meetings held in September and Octtober 2018 (as contained in the Board round-ups for those meetings) and raiise any issues of concern, clarification or interest.

Phil Bellas, Trust Secretary Background Papers: Report of Task and Finish Group on “Holding the Non Executive Directors to Account for the Performance of the Board

Ref. KO 3 Date: 23 10 18

Feedback from Board of Directors meeting held 25 September 2018

Chairman’s report Lesley Bessant announced that she will stand down as chairman on 31 March 2019. This is 12 months earlier than originally anticipated.

Lesley Bessant has presented several Living the Values awards since the last board meeting – she noted these were all well deserved.

Quality assurance committee reporrt The board received and noted this repport. It was decided to review the format of the quality assurance committee agenda to reflect the headings used by the CQC – this will make it easier to track our performance against CQC domains.

The location of emergency response bags in community teams was highlighted and has beeen discussed at the operational management forum and executive management team. Agreed bags will be removed from community units with the exception of those with a clozapine clinic or who administer antipsychotic drugs. Community based staff will undertake CPR training and will also be offered emergency equipment bag BLS trainiing.

Nurse staffing report The board received the monthly reporrt and noted the new format was easier to read.

There was a discussion around serious incidents. Board members recognised there is not a direct link to staffing, however we are starting to see trends in quality of care as a result of staffing. It was agreed thhis matter should be looked intto separately.

It was agreed that the six monthly report will provide more detailed ttriangulation and analysiis.

Learning from deaths report Whilst this report showed an increase in the number of deaths now rreported through Datix, there is still a shortfall, so furtheer work is required to ensure all deaths are reported correctly.

The board discussed our duty of candour. We notify people at the earliest opportunity when there is a problem, however when there is a serious incident we are not always aware there has been a problem until the end of the investigation. The board was advised we always apologise as early as possible, but this is not formally recorded until the end of the process.

Enhanced observations report This paper provided an overview of observation and engagement practice across the Trust. It generated some useful discussion as enhanced observations is frequently referenced in staff reports. The board was informed of current devellopments in new observation practices currently being trialled. Recommendations forr further work in this area were highlighted. This included:

Ref. KO 4 Date: 23 10 18

 possible use of zonal observations, which is less resource inttensive and more effective.  staff visibility on the wards, to ensure people feel safe.  escalations in prescribing – the need to share learning betweeen wards providing comparative care to comparative patients.

Freedom to speak up arrangementts The board considered and agreed sevveral proposed actions from the self-review of our freedom to speak up arrangements. Further work should be done to raise awareness of the various routes available for raising concerns. A summary of information about raising concerns will also be included in the TEWV annual report.

It was agreed that future board reports will include an overview of cases referred to the FTSU guardian, as well as outcomes and lessons learned.

The frequency at which our whistleblowing policy should be reviewed was also discussed. It was agreed this should rremain at every three years.

Finance report The Trrust’s income outturn for the period ending 31 August 2018 showed a surplus representing 2% of the Trust’s turnovver. This is £16k ahead of plan.

Current areas of concern include the use of beds, out of area stays and lengths of stay. The Trust has been experiencing consistent pressure of beds ffor a number of months. This is being reported on to EMT for consideration, with issues including stays over 30 days, high sickness levels and unexpected deaths, which remain above target.

Ref. KO 5 Date: 23 10 18

Feedback from Board of Directors meeting held 30 October 2018

Chairman’s report A governor development day was helld in October which was well received, with governors finding the presentations useful.

Lesley Bessant has recently presented staff with long service awards. She commented on the passion and commitments of the recipients.

Lesley confirmed that the process of rrecruiting a new chairman has commenced.

Locality briefing – York and Selby The board received a presentation on the key issues facing York annd Selby locality.

The main concern is the length of waiiting times for children and adolescent mental health services. In response, a joint piece of work is being undertaken with City of York Council to provide mental health support in schools. A wellbeing service is being expanded across all schools. Work is also underway with the clinical commissioning group and local authorities to look at workforce panning across the system. The benefits of providing support and advice during waiting times, as well as the risks of serious incident, were also considered. More advice could be provided through the Trust website.

The high use of agency staff was also discussed. This is being addressed through the consolidation of the estate, the new hospital and recent recruitment fayres. Different ways of working are also being considered, to reduce the need for agency workers.

Freedom to speak up Guardian The board heard about a recent issue which has highlighted the difffiiculties surrounding exit interviews for staff. An improvement event is being held to look at how feedback from staff leaving the Trust is received, and how exit iinterviews link to the work of the freedom to speak up guardian. There is a current focus on how the Trust can become aware of issues sooner, although it was noted that exit interviews are not the best way to identify issues in teams. There are other mechanisms for staff to raise concerns.

The Trrust’s approach to leadership development in supporting a cultture of raising concerns was discussed. This will feature more prominently is the leadership development programme from 2019.

Nurse staffing report It was agreed that future reports will innclude an assurance statement confirming whether staffing on the Trusts inpatient services was safe.

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It was nnoted that the regulator will be assessing trusts against the new framework from April 2019. A summary will be provided to the board at its December meeting and in the next six monthly report.

Quality assurance committee reporrt This month’s report highlighted the potential issues for forensic services posed by the NHS digital transformation and the roll out of wi-fi across the Trust from October. It was nnoted that forensic services are currently relying on the restrictive practice framework, based on an assessment of individual risk. This will conttinue until a national agreement is reached about internet usage on the wards. Assurance is being sought about the ability to restrict access in certain areas.

Finance report The board notes the Trusts use of resources rating has reduced to 2 as a result of agency staffing expenditure, which is higher than planned and in exccess of the NHSI capped target.

The Trrust is clear on the reasons for the staffing pressures and seeking innovative solutions, eg the medical development department is seeking to bolsster recruitment by introducing the region to the families of prospective employees.

Perforrmance dashboard The focus this month was on waiting ttimes, where performance on KPI1 (percentage of patients seen within 4 weeks) has dropped since May 2018. Workforce and capacity issues are the underlying reasons for this, and work is being undertaken to understand referral patterns and demands on performance, particularly in children and adolescent mental health services. A report will be presented in January 2019 providing an analysis of waiting times with areas for concern and outcome measures, in order to support learning and the development of sustainable solutions.

Constitutional change To reflect the merger of the York and Selby and North Yorkshire loccalities, the board agreed annexes 2 and 4 of the constiitution should be changed to: a) remove North Yorkshire and York and Selby classes within the staff constituency b) establish a new staff class of Norrtth Yorkshire and York, represented by one governor

Security and protection toolkit and general data protection regulation (GDPR) The board received a progress report on the data security and protection toolkit (formerly the information governance toolkit) and the implementation of GDPR.

The number of subject access requests has increased by 24% in quarter 2, which has beeen coupled with the rise in people asking for changes to theirr care records.

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ITEM NO. 8 FOR GENERAL RELEASE

COUNCIL OF GOVERNORS

DATE: 29th November 2018 TITLE: Constitutional Change – Staff Constituency REPORT OF: Phil Bellas, Trust Secretary REPORT FOR: Decision

This report supports the achievement of the following Strategic Goals:  To provide excellent services working with the individual users of our services and their families to promote recovery and wellbeing To continuously improve the quality and value of our work To recruit, develop and retain a skilled, compassionate and motivated workforce To have effective partnerships with local, national and international organisations for the benefit of the communities we serve To be recognised as an excellent and well governed Foundation Trust that  makes best use of its resources for the benefit of the communities we serve.

Executive Summary: The Staff Constituency, described in Annex 2 of the Constitution, is divided into classes based on the Trust’s Localities with a separate class for staff in corporate services. These arrangements are also reflected in the Composition of the Council of Governors (Annex 4 to the Constitution) with each staff class represented by one Governor.

At its meeting held on 25th September 2018 the Board approved the merger of the North Yorkshire and York and Selby Localities.

In order to maintain alignment between the staff classes and the Localities, the Board also agreed, at its meeting held on 30th October 2018, to amend the Trust’s Constitution by merging the North Yorkshire and York and Selby staff classes into a new staff class, “North Yorkshire and York”, to be represented by one Staff Governor.

Under the NHS Act 2006 (as amended) any amendments to a Foundation Trust’s Constitution must be approved by both its Board of Directors and its Council of Governors.

The Board has, therefore, recommended the changes to the Constitution to the Council of Governors for approval.

Recommendations: The Council of Governors is recommended to approve the changes to Annexes 2 and 4 of the Trust’s Constitution (as highlighted in Appendix 1 to this report): (1) To remove the North Yorkshire and York and Selby classes within the Staff Constituency. (2) To establish a new staff class, “North Yorkshire and York”, represented by one Governor.

Ref. PJB 1 Date: 29th November 2018

MEETING OF: The Council of Governors DATE: 29th November 2018 TITLE: Constitutional Change – Staff Constituency

1. INTRODUCTION & PURPOSE:

1.1 On the recommendation of the Board, to seek the approval of changes to Annexes 2 and 4 to the Trust’s Constitution in response to the decision to merge the North Yorkshire and York and Selby Localities.

2. BACKGROUND INFORMATION AND CONTEXT:

2.1 The Staff Constituency (described in Annex 2 to the Constitution) is divided into classes based on the Trust’s Localities with a separate class for staff working in corporate services.

2.2 Under these arrangements each class is represented by one Governor as shown in Annex 4 to the Constitution (Composition of the Council of Governors).

2.3 At its meeting held on 25th September 2018 the Board approved the merger of the North Yorkshire and York and Selby Localities.

2.4 As a result of this decision the Board has also agreed to amend the Constitution to ensure the staff classes remain aligned to the revised Locality structure.

2.5 Under the NHS Act 2006 (as amended), changes to the Constitution require the approval of both the Board of Directors and the Council of Governors.

3. KEY ISSUES:

3.1 Approval is being sought from the Council of Governors to amend the Constitution to replace the staff classes for North Yorkshire and York and Selby with a new class, “North Yorkshire and York”. The new staff class would be represented by one Governor.

3.2 Details of the changes, including consequential amendments, to Annexes 2 and 4 to the Constitution are shown in Appendix 1 to this report.

3.3 Governors are asked to note that: (a) The proposal would result in a reduction in the overall size of the Council of Governors, by one, from 55 to 54. (b) There are no implications arising from the proposed changes for current Governors as both seats are, at present, vacant. (c) If approved, the election of the Governor for the new staff class will held during 2019 as part of the Annual Elections. (d) The membership of the revised staff classes would be as follows (September 2018):

Ref. PJB 2 Date: 29th November 2018

Class No. of Members Corporate 1099 County Durham and Darlington 1497 Forensic 883 Teesside 1435 North Yorkshire and York 1677

4. IMPLICATIONS:

4.1 Compliance with the CQC Fundamental Standards: None identified.

4.2 Financial/Value for Money: None identified.

4.3 Legal and Constitutional (including the NHS Constitution): Changes to the Constitution must be approved by both the Board of Directors and Council of Governors under the NHS Act 2006 (as amended).

4.4 Equality and Diversity: None identified.

4.5 Other implications: None identified.

5. RISKS:

5.1 There are no risks associated with this report.

6. CONCLUSIONS:

6.1 The proposed changes will mean that the staff classes continue to be aligned to the operational arrangements of the Trust.

7. RECOMMENDATIONS:

7.1 The Council of Governors is asked to approve the changes to Annexes 2 and 4 to the Trust’s Constitution (as highlighted in Appendix 1 to this report): (1) To remove the North Yorkshire and York and Selby classes within the Staff Constituency. (2) To include a new staff class, “North Yorkshire and York”, represented by 1 Governor.

Phil Bellas, Trust Secretary

Background Papers: The Trust’s Constitution The NHS Act 2006 (as amended)

Ref. PJB 3 Date: 29th November 2018

Appendix 1 ANNEX 2 – THE STAFF CONSTITUENCY (Paragraphs 8.3 and 8.4)

1. The Staff Constituency

The Staff Constituency is divided into 6 (six) 5 (five) classes based on the Corporate Directorates and Operational Directorates of the Trust. These are:

Class Minimum number of Number of Elected members Governors Corporate 90 1 Forensic 60 1 County Durham and 150 1 Darlington Teesside 180 1 North Yorkshire 80 1 York and Selby 70 1 North Yorkshire and York 200 1

2. Should an individual class within the Staff Constituency fail to achieve the above minimum numbers, no election shall take place in that class, until such time as the minimum number is reached. An election within that class will then take place within a time period determined by the Chairman of the Trust.

3. Staff will only be able to become a member and vote in one class within the Staff Constituency.

Ref. PJB 4 Date: 29th November 2018

ANNEX 4 – COMPOSITION OF COUNCIL OF GOVERNORS (Paragraphs 11.2 and 11.3) COMPOSITION OF THE COUNCIL OF GOVERNORS Constituency Number of Governors from 1/6/17 1/1/19 Public Stockton-on-Tees 3 Hartlepool 2 Darlington 2 Durham 8 Middlesbrough 2 Redcar & Cleveland 2 Scarborough and Ryedale 3 Hambleton and Richmondshire 2 Harrogate and Wetherby 3 City of York 3 Selby 2 Rest of England 1 Staff Corporate 1 Forensic 1 North Yorkshire 1 County Durham and Darlington 1 Teesside 1 York and Selby 1 North Yorkshire and York 1 Appointed Durham County Council 1 Governors Darlington Borough Council 1 Hartlepool Borough Council 1 Stockton-on-Tees Borough Council 1 Middlesbrough Borough Council 1 Redcar & Cleveland Borough Council 1 North Yorkshire County Council 1 City of York Council 1 University of Teesside 1* Durham University 1* University of York 1* University of Newcastle 1* Northern Specialist Commissioning Group 1* North Durham Clinical Commissioning Group 1* Durham Dales, Easington and Sedgefield Clinical Commissioning Group Darlington Clinical Commissioning Group Hartlepool and Stockton-on-Tees Clinical Commissioning Group 1* South of Tees Clinical Commissioning Group Hambleton, Richmondshire and Whitby Clinical Commissioning Group 1* Scarborough and Ryedale Clinical Commissioning Group Harrogate Clinical Commissioning Group Vale of York Clinical Commissioning Group TOTAL 55 54

Ref. PJB 5 Date: 29th November 2018

(Notes: 1 The terms of Governors holding office on 1st June 2017 1st January 2019 are unaffected by any changes to the Constitution which come into force on that day.

2 The appointing organisations marked (*) in the above schedule are specified for the purposes of sub-paragraph 9(7) of Schedule 7 for the 2006 Act (as amended).

3 The arrangements for the appointment of Governors by Clinical Commissioning Groups are set out in Annex 6.)

Ref. PJB 6 Date: 29th November 2018

ITEM NO. 9 FOR GENERAL RELEASE

COUNCIL OF GOVERNORS

DATE: 29 November 2018 TITLE: Update on outstanding action plans

REPORT OF: Phil Bellas, Trust Secretary REPORT FOR: Approval

Executive Summary: This reports seeks to achieve formal sign off by the Council of Governors to a number of action/implementation plans that have been approved by the Council of Governors since 2014.

All actions have been achieved with the exception of two:  The development of a booklet to assist in the marketing, and to raise awareness of the work of the Council of Governors.

 A revision to the Code of Conduct for Governors to manage the behaviour of Governors in holding the Non-Executive Directors to account for the performance of the Board of Directors.

In relation to the outstanding two actions the Council of Governors is asked to agree the priority of these actions and, if still required, to them being carried over to 2019.

Recommendations: For the Council of Governors to approve the completion of the following action/ implementation plans:

Ref. KO 1 Date: 19/11/18

 Implementation of recommendations of Task and Finish Groups: o Holding the Non-Executive Directors to Account for the Performance of the Board o Review of the Conduct of Council of Governors’ Business o Member and Stakeholder Representation and Engagement  Development Plans resulting from the self-assessment of the Council of Governors  Involvement and Engagement Framework Implementation Plan

Ref. KO 2 Date: 19/11/18

MEETING OF: Council of Governors DATE: 29 November 2018 TITLE: Update on outstanding action plans

1. INTRODUCTION & PURPOSE:

1.1 The purpose of this report is to seek the Council of Governors’ approval of the achievement of a number of action plans approved by the Council of Governors.

2. BACKGROUND INFORMATION AND CONTEXT:

2.1 The Council of Governors has approved a number of action plans since 2014 including:

2.2 A number of updates on the progress on the above action/implementation plans have been provided to the Council of Governors, but it is recommended that the Council of Governors review the actions that have been previously agreed and formally sign off the action plans which can be found at Appendix 1 to this report.

3. KEY ISSUES:

3.1 There are two outstanding actions and the Council of Governors is asked to consider that due to the period of time that has elapsed since the action was approved, whether the action is still relevant and a priority whether this has been superseded by other actions/business. The actions that are outstanding are listed below:

3.1.1 The development of a booklet to assist in the marketing, and to raise awareness of the work of the Council of Governors.

(an action from the Task and Finish Group: Member and Stakeholder Engagement and Representation (February 2017) and also the outcome of the self-assessment of the Council Governors of Governors (May 2016)).

Ref. KO 3 Date: 19/11/18

3.1.2 A revision to the Code of Conduct for Governors to manage the behaviour of Governors in holding the Non Executive Directors to account for the performance of the Board of Directors.

(an action from the Task and Finish Group: Holding the Non Executive Directors to Account for the Performance of the Board of Directors)

3.2 In relation to 3.1.2 noted above, the Council of Governors is asked to note that there have been no issues of concern in relation to the conduct of Governors in holding Non-Executive Directors to account for the Performance of the Board of Directors since this action was agreed.

4. IMPLICATIONS:

4.1 Compliance with the CQC Fundamental Standards: No issues

4.2 Financial/Value for Money: No issues

4.3 Legal and Constitutional (including the NHS Constitution): No issues.

4.4 Equality and Diversity: No issues

4.4 Other implications: No issues

5. RISKS: No risks identified. A code of conduct is already in place for Governors and no issues have arisen since the action was agreed.

6. CONCLUSIONS:

The majority of actions have been delivered with only 2 outstanding which have been delayed due to resource implications.

7. RECOMMENDATIONS:

7.1 For the Council of Governors to approve the completion of the following action/implementation plans:

Phil Bellas Trust Secretary

Ref. KO 4 Date: 19/11/18 Ref Date Link to project / Recommendation / Finding Action Action Owner Target date for Status initiative completion

Task and Finish Group - Holding the Non-Executive Directors to Account for the Performance of the Board

Task and Finish Group - Deputy Trust February 2015 1/1 27/11/2014 A rota of Governors to attend Circulate timetable of Closed Holding the Non-Executive Secretary/Head of Board meetings should be Board meetings and Directors to Account for the Member Services introduced. seek expressions of Performance of the Board interest from Governors in attending. February 2015 Closed Produce and circulate rota.

1/2 27/11/2014 Task and Finish Group - The “Board roundup” should be Expansion of the “Board Head of Comms January 2015 Closed Holding the Non-Executive expanded to provide an aide roundup” to highlight Directors to Account for the memoire to assist Governors, material issues Performance of the Board and others attending Board considered by the Board meetings, highlight any business in public business. related matters arising from Compilation of a Trust Secretary January 2015 Closed Board meetings which they quarterly report to the consider important to bring to the Council of Governors attention of the Council of based on the “Board Governors. roundup”

1/3 27/11/2014 Task and Finish Group - Governor membership of Trust Board review of Trust Secretary September 2015 Closed Holding the Non-Executive working groups should continue, Governor Membership of Directors to Account for the irrespective of whether or not Trust Working Groups. Performance of the Board Non-Executive Directors remain members of those bodies, subject to a review in 2015/16.

1/4 27/11/2014 Task and Finish Group - The Board of Directors to be Development of protocol Chief Executive Any required Closed Holding the Non-Executive asked to put in place a process taking into account changes to be Directors to Account for the to enable Governors to provide changes to Director put in place by Performance of the Board feedback, if they wish, on their visiting arrangements. April 2015. observations during Structured Board Visits. 1/5 27/11/2014 Task and Finish Group - The annual progress report on Distribution of the annual Trust Secretary July 2015 Closed Holding the Non-Executive actions arising from Structured Board visit report Directors to Account for the Board Visits should be Performance of the Board distributed to Governors.

1/6 27/11/2014 Task and Finish Group - Reports provided to the Council To be further considered Trust Secretary Task and finish Closed Holding the Non-Executive of Governors should be tailored through the task and group review on Directors to Account for the to its role and duties. finish group on the the operation of Performance of the Board operation of the Council the Council of of Governors. Governors to be completed by February 2015.

1/7 27/11/2014 Task and Finish Group - The Chairman should have full Not applicable. Chairman November 2014 Closed Holding the Non-Executive discretion with regard to the Directors to Account for the participation of Non-Executive Performance of the Board Directors in discussions at meetings of the Council of Governors. 1/8 27/11/2014 Task and Finish Group - A protocol to manage the Development and Trust Secretary May 2015 Outstanding Holding the Non-Executive behaviour of Governors in approval of a revised Directors to Account for the holding the Non-Executive Code of Conduct for Performance of the Board Directors to account should be Governors. included in the Governors’ Code of Conduct. 1/9 27/11/2014 Task and Finish Group - Greater emphasis should be Review of the Deputy Trust Closed Holding the Non-Executive placed on the Council of Governors’ training and Secretary/Head Directors to Account for the development scheme. of Member Governors’ statutory duties in July 2015 Performance of the Board the local training scheme using Services the findings of the review.

1/10 27/11/2014 Task and Finish Group - The Non-Executive Directors Preparation of rota for To commence by Closed Holding the Non-Executive should chair the meetings held chairing meetings Deputy Trust end of May 2015 Directors to Account for the between Governors and between Governors and Secretary/Head of Performance of the Board Directors of Operations. Operational Directors. Member Services 1/11 27/11/2014 Task and Finish Group - Non-Executive Directors should Circulation of dates of Deputy Trust To commence Closed Holding the Non-Executive have an open invitation to attend Committee meetings to Secretary/Head of January 2015. Directors to Account for the meetings of the Thematic the Non-Executive Member Services Performance of the Board Committees of the Council of Directors. Governors. Circulation of agendas for Committee meetings to Non-Executive Directors.

1/12 27/11/2014 Task and Finish Group - The Lead Governor should make Advertisement of the Deputy Trust February 2015 Closed Holding the Non-Executive themselves available prior to availability of the Lead Secretary/Head of Directors to Account for the meetings of the Council of Governor prior to Member Services Performance of the Board Governors to provide advice to Council of Governor any Governor about any matters meetings. concerning them.

1/13 27/11/2014 Task and Finish Group - The Council of Governors should Reviews by task and Trust Secretary Completion of Closed Holding the Non-Executive undertake reviews of: finish groups. task and finish Directors to Account for the group reviews: Performance of the Board How the Council of Governors should undertake its statutory Governor representation of duty on representing the members and the Members and the public. Public – to be determined Arrangements for meetings of the Council of Governors. The operation of the Council of Governors – February 2015. Task and Finish Group - Review of the Conduct of Council of Governors' Business

2/1 22/09/2015 Task and Finish Group - To facilitate greater participation To trial auditorium and Deputy Trust July 2015 Closed Review of the Conduct of and a more informal meeting cabaret seating at Secretary Council of Governors' setting meetings Business 2/2 22/09/2015 Task and Finish Group - Greater awareness of agenda Agenda planning to allow Deputy Trust September 2015 Closed Review of the Conduct of planning and start an end times meetings to last no more Secretary Council of Governors' of meetings than 3 hours during the Business day and 2 hours on an evening

Alternative start times to be 2pm and 6pm depending on season

Indicative timings on agenda for each section

2/3 22/09/2015 Task and Finish Group - Re-development of Council of Use of symbols and Deputy Trust September 2015 Closed Review of the Conduct of Governors’ agenda style photographs Secretary Council of Governors' Descriptions included to Business explain the submission of an item

Clear definition of what is to be agreed and what is information

2/4 22/09/2015 Task and Finish Group - Distribution of Council of Where appropriate all Deputy Trust September 2015 Closed Review of the Conduct of Governors agenda’s and other meeting documents and Secretary Council of Governors' communication communication will be Business sent via email where detail held. Those who request a hard copy distribution will also receive in this way either as the primary contact or in addition to email 2/5 22/09/2015 Task and Finish Group - Reports provided to the Council Reports to highlight key Trust Secretary May 2016 Closed Review of the Conduct of of Governors should be tailored areas of interest/note Council of Governors' to its role and duties and general information Business to be separate Reports to include what actions have been undertaken (where appropriate to address issues reported) Where challenge has been made by the Board of Directors, this should be highlighted within the report or verbally reported at meetings

2/6 22/09/2015 Task and Finish Group - Governor work to be more To disband three Deputy Trust July 2015 Closed Review of the Conduct of aligned to task and finish groups Governor committees Secretary Council of Governors' Business 1. Improving the Experience of Carers 2. Improving the Experience of Service Users A3. GovernorPromoting Oversight Social September Closed Committee to be 2015 established to lead on development of Governor Task and Finish Groups 2/7 22/09/2015 Task and Finish Group - More timely briefings and better Establishment of four Deputy Trust March 2016 Closed Review of the Conduct of informed Governors Governor Development Secretary Council of Governors' Days per year Business Task and Finish Group - Member and Stakeholder Representation and Engagement

3/1 23/02/2017 Task and Finish Group - To ensure that any project Clarify with Planning Deputy Trust March 2017 Closed Member and Stakeholder management, quality and Performance the Secretary Representation and improvement and formal information detailed Engagement consultations processes about Governors and identifies Governors and members in the members as key stakeholders. Project Management Framework including the inclusion of guidance as to when these groups are key stakeholders. To request that the Communications Team embed within their processes notification to Governors of open days, conference events and formal consultations. To request that the Planning and Performance Team consider the submission of quarterly update reports to the Council of Governors on level 1 projects. 3/2 23/02/2017 Task and Finish Group - To ensure that the Council of To undertake an Deputy Trust September 2017 Closed Member and Stakeholder Governors’ Register of Interest is annual review of the Secretary Representation and up to date. Register of Interests. Engagement Governors to notify the Governors Trust Secretary’s Department of any change in the declaration at the point this occurs. 3/3 23/02/2017 Task and Finish Group - To better communicate and To produce an A5 Deputy Trust July 2017 Outstanding Member and Stakeholder market the Council of Governors handy booklet Secretary linked to Representation and and the role of a Governor. publication. action in Engagement Development Plan

3/4 23/02/2017 Task and Finish Group - To consider what training and / For the Involvement Deputy Trust July 2017 Closed Member and Stakeholder or support Governors may need and Engagement Secretary/ Representation and to assist them to engage with the Committee to consider Engagement public, members and any training or support stakeholders. needs required by Governors. To include within the self assessment of the Council of Governors specific questions around training and development. 3/5 23/02/2017 Task and Finish Group - To consider the use of social For in the Involvement Trust Secretary September 2017 Closed Member and Stakeholder media and technology to enable and Engagement Representation and communication and engagement committee to consider Engagement with the membership and how social media stakeholders. could be beneficial.

To review how to use Closed technology as a way to hold conversations, gather views and feedback. 3/5 23/02/2017 Task and Finish Group - To consider the use of social Trust Secretary September 2017 Member and Stakeholder media and technology to enable Representation and communication and engagement Engagement with the membership and stakeholders.

To request that the Closed Executive Management Team review how social media is used by the Trust as a form of communication and engagement. 3/6 23/02/2017 To support Governors to link To work with Deputy Trust July 2017 Closed with their local groups and Communications/ Secretary organisations. Planning and Performance and Governors to ensure that the Single database of organisations held by the Trust is up to date. Provide Governors Closed with the details of the groups and organisations with their constituency For the Involvement Closed and Engagement Team to assist and support Governors to link to their local groups through letters and meeting attendance etc. Ref Date Link to project / Recommendation / Action Action Owner Target date for Status initiative Finding completion

COUNCIL OF GOVERNORS' DEVELOPMENT PLANS

5/1 22/09/2015 CoG Development Holding the Non Delivery of the Task Trust Secretary Nov-15 Closed Plan Executive Directors to and Finish Action Plan Dept Account individually ‘Holding the Non and collectively for the Executive Directors to performance of the Account individually and collectively for the Board of Directors performance of the Board of Directors’

5/2 22/09/2015 CoG Development Raising awareness of The bi-monthly Board Trust Secretary Dec-15 Closed Plan services and staff and visit schedule to be patient views issued for Governors to book a place on a visit (1 governor per visit) 5/3 22/09/2015 CoG Development Improve the way the The establishment Trust Secretary Nov-15 Closed Plan Council of Governors submission and delivery Dept conducts its business of the Task and Finish Action Plan ‘Review of the Conduct of Council of Governors Business’

5/4 22/09/2015 CoG Development To review how The establishment of a Trust Secretary Oct-15 Closed Plan Governors can engage Task and Finish Group Dept and represent to review engagement members and and representation of stakeholders members and stakeholders 5/5 22/09/2015 CoG Development More structured Move to quarterly Trust Secretary Jan-15 Closed Plan briefing processes Government Dept around key Trust Development Days with developments and a mix of briefings and issues training delivery

6/1 19/05/2016 CoG Development To refresh the To issue a schedule of Deputy Trust Jul-16 Closed Plan Governor Training internal training events. Secretary programme. To issue a schedule of Governwell (external) training events.

6/2 19/05/2016 CoG Development To have greater Non Executive Deputy Trust Jun-16 Closed Plan contact with Non Directors invited to: Secretary / Executive Directors. Governor Development Governors Days. (4 per year)

Council of Governor Meetings (5 per year) Meetings with Directors of Operations (2 per year) Governors invited to attend Board and EMT visits to services (approx. 7 visits on a bi monthly basis) 6/3 19/05/2016 CoG Development To hold Chairman/Non Dates to be set within Deputy Trust Sep-16 Closed Plan Executive / Public meeting schedule. Secretary Governor meetings twice per year. Non Executive Directors to be informed of meeting dates.

6/4 19/05/2016 CoG Development Governors to influence Governors to suggest Deputy Trust Jun-16 Closed Plan the agenda setting for items for future Secretary Governor agendas of Governor Development Days. Development Days.

6/5 19/05/2016 CoG Development Raising awareness of For the Task and Finish Task and Nov-16 Outstandin Plan the work of the Council Group looking at Finish Group g and of Governors. Member and members linked to Stakeholder action in representation and task and engagement to consider finish group and recommend to the Council of Governors a proposed booklet.

19/05/2016 CoG Development To ensure that the To contact appointing Trust Secretary Aug-16 Closed Plan Council of Governors organisations to seek Dept is fully representation representation. in terms of its membership To include within 6/6 induction events the importance of involvement of those Governors appointed by stakeholders. Ref Date Link to project / Recommendation / Finding Action Action Target date Status initiative Owner for completion

Involvement and Engagement Framework Implementation Plan

4/1 17/11/2015 Involvement and To develop a procedure to To write a procedure Deputy March 2016 Closed Engagement Framework underpin the Involvement and Trust Implementation Plan Engagement Framework Secretary

4/2 17/11/2015 Involvement and To refresh the Involvement and To provide a Deputy December Closed Engagement Framework Engagement Database comprehensive register Trust 2015 Implementation Plan ensuring it is fit for purpose to of those wishing to be Secretary deliver the Framework involved in the Trust including their interests, experience, aspirations and progress on their Involvement Journey

4/3 17/11/2015 Involvement and To review contact mechanisms To develop literature Deputy December Closed Engagement Framework for people wishing to be and information on how Trust 2015 Implementation Plan involved/engaged with the to be involved in the Secretary / Trust and publicise these. Trust PPI Officers

4/4 17/11/2015 Involvement and To review and gain Council of Produce a report to the Deputy November Closed Engagement Framework Governor approval to Council of Governors Trust 2015 Implementation Plan governance arrangements to following consultation Secretary support delivery of the with the Making the Framework Most of Membership Committee 4/5 17/11/2015 Involvement and To develop monitoring, To develop monitoring Deputy March 2016 Closed Engagement Framework reporting and assurance mechanism for Trust Implementation Plan mechanisms involvement activities Secretary To gain approval of the Deputy September Closed Involvement and Trust 2015 Engagement Secretary Scorecard 4/6 17/11/2015 Involvement and To improve the diversity of Targeted activities Deputy March 2016 Closed Engagement Framework people included on the linked to membership Trust Implementation Plan Involvement database recruitment Secretary

4/7 17/11/2015 Involvement and To provide a consistent To develop a Deputy March 2016 Closed Engagement Framework approach to supporting mechanisms for Trust Implementation Plan individuals on the Involvement supporting individuals Secretary / Register on their Involvement PPI Officers Journey 4/8 17/11/2015 Involvement and To provide clarity on the To develop an Deputy Trust December Closed Engagement Framework expectations for those involved involvement compact Secretary / 2015 Implementation Plan in the Trust agreement including PPI Officers role descriptions where applicable 4/9 17/11/2015 Involvement and To have meaningful, To provide advice and Deputy Trust March 2016 Closed Engagement Framework accessible, proportionate and guidance on the Secretary/He Implementation Plan proactive involvement development of groups ad of /feedback groups across the and seek involvement Member Trust membership Services / PPI Officers / Trust services 4/10 17/11/2015 Involvement and To review the provision of Kaizen event Deputy Trust December Closed Engagement Framework honoraria and travel and Secretary 2015 Implementation Plan subsistence payments for involvement and engagement activities

4/11 17/11/2015 Involvement and To review engagement Commission Trust January Closed Engagement Framework arrangements in AMH services independent review Secretary 2016 Implementation Plan at Locality and Directorate levels 4/12 17/11/2015 Involvement and As per action plan Trust March 2016 Closed Engagement Framework To implement the action plan Secretary Implementation Plan from 11 above

ITEM NO. 10 FOR GENERAL RELEASE

COUNCIL OF GOVERNORS PUBLIC AGENDA

DATE: 29 November 2018 TITLE: To assure the Council of Governors on the position of compliance with the Care Quality Commission and Ofsted registration requirements REPORT OF: Jennifer Illingworth, Director of Quality Governance REPORT FOR: Information

This report supports the achievement of the following Strategic Goals:  To provide excellent services working with the individual users of our services and  their carers to promote recovery and wellbeing To continuously improve to quality and value of our work  To recruit, develop and retain a skilled, compassionate and motivated workforce To have effective partnerships with local, national and international organisations for  the benefit of the communities we serve To be recognised as an excellent and well governed Foundation Trust that makes  best use of its resources for the benefits of the communities we serve.

Executive Summary:

This report provides an update on the Trust’s activity in providing assurance on the current position of compliance with the Care Quality Commission (CQC) and Ofsted registration requirements and covers:

 Trust Inspection 2018  Trust Inspections: since submission of the previous report there have been: - 6 CQC MHA Review inspections to wards  Update on the Quality Compliance Group  Update on the Peer Review Inspection Programme  Update on the CQC Engagement meetings

Recommendations:

The Council of Governors are asked to note the CQC and Ofsted registration / information assurance update.

Council of Governors – November 2018 1 Report created 12 November 2018

MEETING OF: COUNCIL OF GOVERNORS DATE: 29 November 2018 TITLE: To assure the Council of Governors on the position of compliance with Care Quality Commission registration requirements.

1. INTRODUCTION & PURPOSE

1.1 To provide the Council of Governors with a position statement on the Trusts Care Quality Commission (CQC) and Ofsted registration and provide assurance of compliance with the Fundamental Standards for Quality and Safety required to maintain registration.

2. KEY ISSUES:

2.1 Trust CQC Inspection 2018

On the 23 October 2018 the CQC published its latest reports following the announced and unannounced inspections which took place between 12 June and 25 July 2018. The trust maintained the overall rating of ‘Good’ and the reports contain some very positive feedback about our services. The inspectors commented that staff worked hard to provide quality care, with services meeting the needs of our service users. The CQC felt that staff displayed a positive attitude about their role, were motivated and skilled, and that the Trust has effective leadership and support in place. Staff and service users felt listened to and service users are treated with dignity and respect.

Several examples of outstanding practice were referenced in the report, including:  Community based AMH services – access to psychological therapies was thought to be excellent and waiting times low.  MHSOP wards – inspectors were impressed that staff are actively encouraged to get involved in quality improvement projects to improve service delivery and patient care.  CAMHS wards – use of the ‘stop the line’ process at the Evergreen Centre had a positive impact on staff morale.  Acute adult wards – excellent practice was noted in the implementation of the Triangle of Care on Ward15, North Yorkshire and also the psychiatric intensive care unit pathway – the PICU pyramid – was highlighted as good practice in reducing unnecessary admissions to the units.

In addition to our overall rating, the Trust also achieved individual ratings of Good against four of the five criteria.

Council of Governors – November 2018 2 Report created 12 November 2018

The fifth criteria services were assessed against is safety. This is the one area in which the Trust was rated as Requires Improvement, remaining the same as the last inspection.

The reasons for this include some issues with risk management plans, monitoring and auditing of services, accommodation and staffing levels on some of our wards. The Trust is aware of the ward environmental issues in some parts of the Trust, and plans are in place to address these. There has also been investment in nurse staffing in some adult wards, and this was recognised by the inspectors. The Trust continues to recruit and train new nurses with a programme in place covering all areas of the Trust.

The core services ratings can be viewed below which detail ratings against each of the five criteria. The overall ratings, included those awarded in previous inspections were aggregated along with this inspection to provide the final overall rating for the Trust.

Under Regulation 17(3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, the Trust are required to submit a written report of the actions it will take to meet the Health and Social Care Act 2008 and any other associated regulations where a breach was identified. The deadline for the report of actions is due on 20 November 2018.

The final reports can be viewed on the CQC’s website here.

Council of Governors – November 2018 3 Report created 12 November 2018

2.2 Trust Inspections

CQC Long Stay / Rehabilitation Report – Final Report

The final report was received on 27 September 2018 and there were two issues identified where the Trust was not meeting legal requirements under Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment:

1. Patients did not have access to nurse call points and had to verbally call for help. 2. Staff on Talbot ward had not identified all ligature points during environmental risk assessments.

The Trust has developed a report on actions completed to address the above which was submitted to the CQC on 26 October 2018.

CQC MHA unannounced inspections

Since presentation of the previous report to the Council of Governors there have been 6 unannounced CQC MHA inspections.

Type of Inspection Locality Speciality Ward/Team Inspection Date MHA Y&S MHSOP Meadowfields 13/09/2018 MHA NY MHSOP Ward 14 25/09/2018 MHA NY AMH Esk Ward 26/09/2018 MHA Tees AMH Bilsdale Ward 09/10/2018 MHA Y&S LD Oakrise 17/10/2018 MHA D&D ALD Bek Ward 7/11/2018

2.3 Her Majesty’s Inspectorate of Prisons (HMIP) and CQC Prison Inspections

HMP Durham Mental Health Team and Integrated Support Unit: 1 October 2018

On 1 October 2018 inspection of HMP Durham was carried out in partnership with Her Majesty’s Inspectorate of Prisons (HMIP) and the Trust are currently waiting for the final report.

2.4 Ofsted Registration – Holly and Baysdale

A meeting took place at Holly Unit on 5 October with the Children’s Lead for the CQC to review the purpose and function of the unit and look at the care delivered there. The initial outcome of the meeting indicated the CQC would recommend the unit as a health provision. The inspectors are due to have further meetings with senior managers and a formal decision will be conveyed to the Trust shortly. The CQC are also now considering re-review of the registration at Baysdale Unit. The Trust have Council of Governors – November 2018 4 Report created 12 November 2018

provided the CQC with a summary of the functions and service provided by Baysdale for review and decision.

2.5 Quality Compliance Group

The Quality Compliance Group met on 28 September where the findings of the draft CQC report were presented and discussed.

2.6 Fundamental Standards Group

The Fundamental Standards Group last met on 7 September 2018. An update was provided to the group around the unannounced core services and well-led inspection. A presentation and discussion took place regarding outcome focussed mental health and feedback and discussion regarding the peer review inspection programme.

2.7 CQC Engagement Meetings

The CQC engagement meetings have been suspended during the Well-led inspection. The meetings are scheduled to re commence from November 2018.

3. IMPLICATIONS

3.1 Compliance with the CQC Fundamental Standards: Provision of safe and effective high quality services is a strategic priority for the Trust and the Fundamental Standards of Quality and Safety that underpin CQC registration support and facilitate those quality services.

3.2 Financial/Value for Money: Full CQC registration is an essential requirement of the NHS Improvement authorisation the Trust to operate as a Foundation Trust

3.3 Legal and Constitutional (including the NHS Constitution): Under the 2008 Health and Social Care Act (Regulated Activities) Regulations 2009,

CQC registration is a pre-requisite to the status of service provider – the Trust can no longer legally undertake contractual obligations to provide services without registration for those services.

3.4 Equality and Diversity: The Equality and Diversity legislation underpins the CQC registration framework and therefore compliance with E&D legislation is monitored to mitigate risk to or compromise of CQC registration status.

4. RISKS

The essential requirement to have services registered before undertaking contractual obligations to provide could compromise the flexibility and nimbleness of the Trust to

Council of Governors – November 2018 5 Report created 12 November 2018

take on new or reconfigured services as the registration processes are not currently highly responsive

5. CONCLUSIONS

The Trust continues to maintain full registration with the CQC with no conditions and continues to strengthen the validated evidence base that demonstrates compliance with the CQC’s framework for regulating and monitoring services.

6. RECOMMENDATIONS

The Council of Governors is asked to note the information provided within this report.

Jennifer Illingworth Director of Quality Governance November 2018

Council of Governors – November 2018 6 Report created 12 November 2018

ITEM NO 11 FOR GENERAL RELEASE

COUNCIL OF GOVERNORS

DATE: 29 November 2018

TITLE: Service Changes Report

REPORT OF: Ruth Hill, Chief Operating Officer

REPORT FOR: Information

This report supports the achievement of the following Strategic Goals:  To provide excellent services working with the individual users of our services  and their carers to promote recovery and wellbeing To continuously improve to quality and value of our work  To recruit, develop and retain a skilled, compassionate and motivated  workforce To have effective partnerships with local, national and international  organisations for the benefit of the communities we serve To be recognised as an excellent and well governed Foundation Trust that  makes best use of its resources for the benefits of the communities we serve.

Executive Summary:

This report sets out high level developments within services across localities and specialties.

Recommendations:

Council of Governors is asked to receive and note this report.

Ref. PJB 1 Date:

MEETING OF: Council of Governors DATE: 29 November 2018 TITLE: Service Changes Report

1. INTRODUCTION & PURPOSE:

1.1 To provide an update on service changes within Tees, Esk and Wear Valleys NHS Foundation Trust.

2. BACKGROUND INFORMATION AND CONTEXT:

2.1 This paper seeks to provide an overview for Governors regarding some of the key current service issues. The update is set out by locality and service.

3. KEY ISSUES:

3.1 Durham and Darlington

Adult Mental Health and Substance Misuse Acute Services We have now concluded our pre engagement exercise around the Crisis Recovery House in Shildon and have analysed all the feedback we have received. Linking with the Clinical Commissioning Group’s (CCG) review of the overall crisis pathway, and discussing with stakeholders we have now almost finished developing more specific options for the future which will allow us to make maximum use of the resource we have. Developments are likely to include establishment of peer workers, more creative approaches to “safe havens” and refreshing our approach to intensive home treatment.

Linked to this work, we are progressing well with plans to redesign our approach to crisis services, learning from feedback we have received and approaches that work elsewhere. The crisis teams have been instrumental in leading this work and it is expected that a new model, using a ‘hub and spoke’ concept, will be in place by 1 April. We and our commissioners are very excited about the potential opportunities these developments will bring to improving how we are able to prevent and support people in crisis across Durham and Darlington.

Specialist Services The new Perinatal Mental Health service in Durham and Darlington is now almost fully operational. Staff have been appointed and are beginning to take up post. We are expecting the service to be operational in the New Year.

Improving Access to Psychological Therapies (IAPT) We have submitted a bid for the new IAPT provision across Durham and Darlington and Tees in partnership with Mental Health Matters and

Ref. PJB 2 Date:

Sunderland Counselling Service. The successful bidder will be notified at the end of November.

Mental Health Services for Older People Focus from Falls to Frailty Falls is one of the five recognised frailty syndromes and therefore needs to be assessed as part of the complexity of frailty. We have now developed and piloted an inpatient Frailty Clinical Link Pathway (CLiP) in 5 MHSOP wards across the Trust. This process has been rigorously tested over a 12 month period. During this period the CQC observed the ward Frailty meetings and have provided positive feedback on the Multi-Disciplinary Team process. From October 1st 2018 all MHSOP inpatient wards within Durham and Darlington, and Teesside have rolled out the Frailty CLiP.

Alongside this, work has been completed on an electronic Frailty CLiP on PARIS (electronic care record). We now have a test version which is going to be tested within teams on the 19th October 2018.

Pain Management It is usual practice within MHSOP that all patients on admission are assessed for pain and are then assessed regularly throughout their admission. We have developed an acute and chronic pain algorithm which outlines assessment and management of pain for all MHSOP inpatients. A yearly pain assessment and management audit is completed.

Patient and Carer Experience Durham and Darlington MHSOP wards; Roseberry, Oak, Ceddesfeld and Hamsterley were all rated 100% recommended in the most recent Friends and Family test scores.

Children and Young People’s Services General Waiting Times The service continues to sustain waiting time targets for the initial assessment within 4 week of referral; however we continue to under achieve for the target for second appointment in nine weeks. The increase in referrals continues to impact on capacity to meet demand. Caseloads remain high with little capacity to allocate new cases within the timeframe. All young people waiting are allocated to a clinician and have the date for their next appointment. Team managers continue to review cases waiting and where there are opportunities to bring forward appointments this is offered to the young person and/or their family. All team managers are working on a trajectory of when they will be able to achieve the target. This is influenced by any staff sickness or vacancies.

A key to capacity is staff retention; any gaps in staffing impact on the ability to allocate new cases. Staff engagement in our business planning process highlighted staff wellbeing as an area to focus on to improve staff retention. The consultant psychologists in each team will work with the teams to agree umbrella goals/strategies to improve staff wellbeing.

Ref. PJB 3 Date:

The service has participated in a further two events with the Mental Health School Link programme which was facilitated by the Anna Freud Centre. This has enabled us to work with partners such as the local authority, public health, education and over 120 schools within County Durham & Darlington to work closer together, strengthening our understanding of roles and enhancing the emotional wellbeing provision within schools. This work should also support appropriate admissions to Child and Adolescent Mental Health Services (CAMHS).

Autism Spectrum Disorder (ASD) Waiting Times The new team is now operational and is based across two sites, one in Holly Ward in West Park and the other in Stanley Health Centre. The waiting time trajectory against current demand is that by June 2019 there will no longer be a wait for an Autism assessment for young people.

Learning Disability Service STOMP Pledge (Stopping the over-medication of people with a learning disability, autism or both) The Trust has signed up to the STOMP Pledge and has a small team including pharmacists, medics and nurses leading on the project.

It is estimated that on an average day in England between 30,000 and 35,000 people with a learning disability, autism or both are taking prescribed psychotropic medication without appropriate clinical justification. Long-term use of these medicines puts people at unnecessary risk of a wide range of side effects including weight gain, organ failure and even premature death.

There is a range of activities across the patch, including consultant psychiatrists working with GPs, to complete medication reviews, working with Primary Care to help people identify the right support needed. There is a non- medical prescriber (NMP) who is also a trained positive behaviour support practitioner running STOMP clinics where both medication and behavioural support can be considered.

3.2 Tees The Private Finance Initiative contract for Roseberry Park Hospital has been terminated. The Trust is now responsible for the running of the hospital buildings. Termination of the contract allows the Trust to move forward rectifying the extensive construction defects at the hospital.

Adult Mental Health and Substance Misuse The Adult Autism Team for Tees, Durham & Darlington continues to have a rise in referral rates from an average of 18 per month to 50 per month. A business case is to be submitted this month to the Clinical Commissioning Group for additional resource.

The Adult Attention Deficit Hyperactivity Disorder Service for Tees, Durham & Darlington has seen a marked increase in its referral rates from an average of 16 per month to 40 per month. A Task & Finish group has been set up to

Ref. PJB 4 Date:

develop plans to manage increasing referrals with plans to develop a neurodevelopmental service.

Referral rates to Crisis Teams across Teesside remain high. The crisis review undertaken by South Tees Clinical Commissioning Group on behalf of themselves and Hartlepool and Stockton Clinical Commissioning Group is now complete. The review is now with Tees Esk and Wear Valleys NHS Foundation Trust for comment.

Mental Health Services for Older People Tees MHSOP were successful this month in receiving two Royal College of Psychiatry awards:

Psychiatric Team of the Year: Quality Improvement Specialty Doctor / Associate Specialist of the Year - Dr Thandar Win

Dementia Care Pathway Following the publication of the new National Institute for Clinical Excellence (NICE) dementia guidelines the service has recently carried out a review of its dementia care pathway with a planned roll out in November 2018.

Children and Young People’s Services Inpatient services have been involved in a series of quality improvement events with the aim of ensuring a purposeful and productive inpatient stay. Following these events there has been a reduction in inpatient bed usage and a reduction in length of stay; the events have promoted significant quality improvements within our inpatient wards.

An increase in referrals is being seen across all community teams and we are placing an emphasis on staff wellbeing across services. Staff continue to demonstrate commitment to deliver high quality care in very demanding times.

Additional financial support was received from Hartlepool and Stockton Clinical Commissioning Group to develop initiatives to reduce the current waiting list for Autism Spectrum Disorder assessment within their locality. The plans for the model of delivery have been made and work on the over 5s waiting list has commenced.

Learning Disability Service The Durham Darlington and Teesside Mental Health and Learning Disability Partnership has expanded initial case management work to include a further 1000 service users from across Durham Darlington and Teesside. A case management work stream has been established to ensure that all service users receive a case management review. The review will ensure that current care provision remains relevant, appropriate and meets the needs of the service user in the most efficient manner. It is anticipated that the case management review process will support the effective delivery of the transforming agenda through an effective whole systems based approach.

Ref. PJB 5 Date:

The Intensive In-reach Team has recruited three registered nurses who are working alongside a number of providers to prevent placement breakdown, hospital admission and support the smooth transition of care from one care provider to another. An options appraisal has been completed, benchmarked against national guidance on the model of service delivery, which is to be finalised before the end of the year.

Discussions continue to take place with commissioners to agree how the chosen respite provision option of bed based respite services, augmented with more community based forms of delivery, will be progressed.

3.3 North Yorkshire

Adult Mental Health and Substance Misuse Hambleton and Richmondshire transformation will formally commence with the planned cease of admissions to the Friarage Hospital from the beginning of January 2019, with the expectation of the ward being closed by the end of February. Harrogate transformation is on track to commence formal discussion with the public from December, following review with NHS England.

There has been successful recruitment into the North Yorkshire and York perinatal mental health team, which will mean that we will soon be able to offer enhanced access and support for this high risk group of women.

Recruitment of staff remains problematic in the locality, with particular challenges for the inpatient unit in Harrogate. The targeted efforts to recruit to the Ayckbourn Unit have resulted in much improved team establishments. This will enable to the opening of a bed on each ward from January 2019.

New consultant jobs plans are being introduced across the locality because of the successful recruitments (locum & substantive) across the service.

Mental Health Services for Older People Harrogate Community Mental Health Team were shortlisted for the Nursing Times Team of the Year award and members of the team recently attend the prestigious awards ceremony. Although they did not win the overall prize it was a fantastic achievement to be shortlisted.

A new Community and Memory Service Team Manager is also working with the team in Hambleton and Richmondshire to devise a recovery plan for the Memory Service to address the caseload pressures and waiting times issues. We are already seeing some improvement in waiting times but expect to see a significant improvement from January 2019 including increasing opportunities for people diagnosed with dementia to attend Cognitive Stimulation Therapy. Rowan Ward, Harrogate have updated and refreshed their use of the Purposeful Inpatient Admission (PiPA) process which has included changes to the location and way that report outs are done which is helping to improve patient outcomes and reduce length of stay. Staff from our ward in

Ref. PJB 6 Date:

Scarborough, Rowan Lea, also attended the Royal College of Psychiatrists conference in London recently to present their work on PIPA for the most sustained improvement.

A new team manager has been appointed to lead the Acute Hospital Liaison Team and the Older Persons Crisis Team following the retirement of the previous manager and they are working closely with colleagues in Harrogate District Foundation Trust to ensure plans are in place to support the Emergency Department during anticipated winter pressures.

Children and Young People’s Services Approval has been given to start work on developing a 24/7 CAMHS crisis team across North Yorkshire and York. An away day was held in late October to start looking at developing options around how this service will operate. Further work is going to be undertaken in November to appraise these options and make progress towards the new service being operational in quarter one of 2019. The current service operated 10am to 10pm seven days per week and it sits within the Tier 4 Models of Care programme.

We continue to look at how we actively engage children, young people and their parents/carers in service redesign. To support taking this work forward we have successfully recruited a part-time recovery lead for North Yorkshire. Over the last quarter all teams have held open days for children, young people, parents and professionals as part of celebrating NHS 70th birthday. These have been a great success. In Northallerton young people attended a 2 day event to co-produce a revised approach to our cognitive based therapies group. This is currently being piloted in Northallerton with view to roll out across the locality.

The service continues to sustain waiting time targets for an initial assessment within 4 week of referral. However we have experienced deterioration in the target for second appointment in nine weeks and this is currently at 88%. This is linked to recent staffing pressure in the Scarborough team and the increase in referrals across the service. An action plan has been developed to support achievement of the target going forward in Scarborough. We plan to meet with commissioners and partners in December to explore pathways across the services.

Learning Disability Service Transforming Care The programme is due to complete in March 2019 and plans are being developed for what the revised programme will look like and linking to the NHS 10 year forward plan. Enhanced community model development is continuing within North Yorkshire, York and Selby and is looking at alignment with the wider Trust work on bed configuration and linking to a planned Inpatient Rapid Process Improvement Workshop (RPIW) in January 2019. Clinical Commissioning Groups/ Transforming Care Partnership have stated they are unable to fund the proposed Community Crisis Intervention Service and are asking this to be a priority for the next year under the Accountable Care Partnership. As an interim they have offered to fund a band 7 post for a

Ref. PJB 7 Date:

further 12 months. A paper is to be sent to the Executive Management Team in November regarding options and relationship to plans for an enhanced community offer. The Forensic Secure Outreach has been secured and recruitment is in progress with a plan to be referral ready by Jan 2019.

Inpatient bed pressures There continue to be difficulties re inpatient beds, delayed discharges and lack of commissioning progress to facilitate discharges when appropriate. However we have a monthly call with commissioners to discuss these issues and blocks.

Recruitment and Retention We have a number of senior clinical staff leaving the service in the coming months (in particular clinical psychology and occupational therapy) and are under way with trying to recruit into posts. We remain on an interim arrangement under ‘Mind the Gap’ for the consultant psychiatrist for Scarborough, Whitby and Ryedale service as we have not yet found a solution, although there is a potential solution currently being explored.

Purposeful and Productive Community Service (PPCS) Refresh – the Hambleton and Richmondshire Learning Disability team have worked hard to embed and embrace some of the new ways of working and shown positive improvements as regards reductions in process times – plans to look at rolling out this learning across all teams to start in December linking in with a planned Rapid Process Involvement Workshop for the whole Learning Disability Speciality in February 2019.

3.4 York and Selby Adult Mental Health and Substance Misuse Improving Access to Psychological Therapies (IAPT): The team continues to find the access target challenging linked to workforce difficulties in terms of recruitment and retention. The IAPT Service has now received two Intensive Support Team reports from NHS Improvement with a further visit planned for December 2018 with a focus on prevalence. York & Selby are staff presenting to the CCG Contract Management Board November with updated position for the service.

Early Intervention: The team continues to experience significant difficulties with recruitment and retention; two new starters have joined in October 2018. NHS England have planned a deep dive visit, date to be confirmed.

Perinatal services for North Yorkshire & York and Selby are now fully recruited to following a successful recruitment programme. The team manager has commenced in post and the team were part of a Trust wide Kaizen event week commencing 22nd October.

Rehabilitation & Recovery services, the locality has piloted a community based rehabilitation and recovery service (12 month pilot planned). This team has been successful in terms of repatriating local residents from out of locality

Ref. PJB 8 Date:

private hospitals, also leading to significant financial savings. Formal evaluation of the pilot is ongoing. Dates to be confirmed with CCG for public consultation on the formal closure of Acomb Garth as a rehabilitation and recovery unit (currently used to provide male dementia services). Mental Health Services for Older People Service transformation plans A further development day with the teams resulted in a number of different pilots exploring alternative ways to deliver enhanced community services. For example, developing an access service for MHSOP, aligning cells to GP clusters, and developing the role of the band 3. Emphasis is placed on early intervention and prevention of unnecessary hospital admissions.

Inpatient Services EMT approved the proposal to merge the two organic units into one single mixed sex 18 bed unit by the first of July 2019. Meadowfields Unit will undergo the necessary estates work to ensure CQC and Eliminating Mixed Sex Accommodation (EMSA) compliance.

All three inpatient units continue to manage high acuity and therefore higher levels of bank and agency use than expected. This continues to be reviewed and monitored via daily lean management.

Memory Service The number of service users waiting for an initial assessment continues to increase due to further sickness and vacancies within the team. Short term contingency plans have been put in place to manage the immediate issues with additional work commenced to undertake a thorough review of the service and develop a business case for any future potential investment. This would include developing the right workforce model and a trajectory to eliminate the waiters.

Medics There are impending changes with the community medical workforce as two members of the team have left. It is anticipated a locum consultant will be employed in the interim until the changes occur in the inpatient units which will release medical capacity and whilst we develop the community model and explore opportunities for introducing nurse consultant roles.

Children and Young People’s Services The service continues to have capacity and demand issues and is looking at different ways of providing services to address this. It is introducing a group work approach for children and young people who are experiencing anxiety and depression. A rapid progress improvement workshop has been arranged for February 2019 to review the impact of this new approach and review the benefits from a young person’s perspective.

The service has been reviewing its skill mix and has invested in 2 clinical psychology assistant posts and 2 additional clinical psychologists to work on all of the clinical pathways. Alongside this, 2 additional band 6 CAMHS practitioner posts have been recruited to and will provide additional

Ref. PJB 9 Date:

assessment and intervention capacity. These new starters are scheduled to start in October/ November 2018.

Whilst the additional staff are essential to improve the waiting times within the service, it does however create additional pressure on the CAMHS estate in both the York and Selby bases. The Selby team will be included in the new Selby hub, once a suitable site has been identified, which will improve the situation enormously. Further work is continued to explore solutions to address overcrowding on the Limetrees site.

The service is looking at how to increase meaningful user/ carer feedback into future service development and quality assurance. The Chair of the local Parent Forum has been invited to join the monthly Quality Assurance Group to help develop a robust participation strategy.

Development of the CAMHS Recovery College continues, with the appointment of the recovery leads across the localities increasing the momentum of this.

Learning Disability Service The service continues to see good results from the improvement event in June. All patients are allocated for an initial assessment within 2 working days and seen within four weeks unless they do not attend or choose a different date.

The new huddles and leadership group (supercell) have improved communication and recovery focus and there is an improvement in staff wellbeing. Staff are using technology to directly input notes where this is appropriate and this has again demonstrated significant improvements in the length of time from a visit to the notes being on the system, releasing travel time and reducing the likelihood of interruptions.

The challenges at Oak Rise continue in terms of bed use and complexity of patients. However there is a new team manager in post and the recruitment drive has resulted in several new starters who are all now in post. The effect of the bed position has led to Greenlight admissions and more creative and collaborative work from the community service to prevent admission.

The Trust now has representation at the Yorkshire and Humber Operational Delivery Network who are going to develop work streams around what is a good community infrastructure (for people with learning disability, non-learning disability, autism and children), carer/ service user engagement and network, risk management that supports positive risk taking, rehabilitation services and investment in developing structure/network including technology strategies. NHS Improvement is supporting this.

There is ongoing work with North Yorkshire locality to develop a business model for an enhanced community service. An options appraisal will be completed and a model proposed at both Trust and Transforming Care Partnership boards.

Ref. PJB 10 Date:

The Forensic Outreach Liaison Service is being recruited to and will hope to be operational in the new year.

3.5 Forensic Services

Estate/Security Issues The rectification programme at Roseberry Park continues to require considerable operational and clinical involvement and in order to facilitate the rectification programme Brambling ward will move from its current block to a vacated area within another block on 19th November. This will fully vacate a Block in preparation for the rectification works to commence. The new main car park is due for completion in November and construction of Block 16 will commence in February 2019. There are three construction companies who have applied to undertake the rectification programme and an interview process will determine who is awarded the contract.

Nurse Staffing 12 Newly registered nurses took up post in September / October 2018 and are undertaking an extensive induction programme to support their roles. We have recruited a nurse consultant to the north west prison teams, based initially in Haverigg, to develop the nursing workforce and support high quality care provision.

Model Ward Programme Recovery Meeting – 120 day report out took place for the Recovery Meeting RPIW and reported all meetings on the two pilot wards have been 100% value added, with no waste or repetition and 100% service user attendance. Set up reduction was used to remove steps from the meeting process which were repeated or did not add value, saving 115 hours of nursing and Responsible Clinician time and the next step is for a planned roll out of the process to all wards in Forensic Mental Health and Forensic Learning Disabilities.

Recovery Pathway/Set-Up Reduction RPIW This event considered opportunities for improving the admission process; to make it more recovery focused and ensure information is collected at the earliest possible opportunity. This will ensure that treatment starts as early as possible, and that the start of the service user journey flows better. A framework was created to ensure that vital information is captured at the point of assessment, a new admission checklist was created and this should streamline the process and reduce the burden on nurses at the point of assessment. At 30 days the new checklist reduced nursing time completing tasks by 37%.

Observations & Engagement Kaizen – It was identified that more robust processes for reviewing and reducing service users continuous engagements and observations were required and this event developed a pack which informs multi-disciplinary team reviews of observations at commencement and every 24 hours. The process brings service users into the reviews and

Ref. PJB 11 Date:

encourages goal setting with service users and collaborative planning for reducing continuous engagements and observations. The new process was piloted during the Kaizen, and a service user who was expected to be under continuous engagements and observations for three days had this reduced to three hours. The process is being piloted on all female wards.

Patient Property Innovation Event Service users and staff on Brambling ward worked together to rationalise the amount of property kept in bedrooms, agreed a process to prevent excessive property in rooms and are working to develop a collaborative intervention plan to address the issue of excessive property. As a result, far less property is being stored in individual bedrooms.

Forensic Learning Disability - Transforming Care and Secure Outreach and Transitions Team (SOTT) The implementation of NHS England’s (NHSE) Assuring Transformation Programme continues to be the most significant issue facing the service. We continue to meet with NHSE and Northumberland Tyne and Wear colleagues to manage the bed trajectories across the region but these are becoming ever more challenging. The service is working through a number of actions to try to ensure that the bed trajectory figure can be realised by 31st March 2019.

The North Yorkshire and York Secure Outreach Transitions Team mobilisation phase continues and we have recruited to a number of the posts including Team Lead and Advanced Practitioner with remaining vacancies advertised.

Forensic Learning Disability and Forensic Mental Health Inpatient Service Across the inpatient services at Roseberry Park Hospital we are experiencing a high level of patient acuity and challenges resulting in increased levels of additional observations and seclusion resulting in significant and ongoing staffing pressures particularly for nursing. Two recently recruited speech and language therapists are now in post which is a very positive.

The New Care Model Partnership continues and a recent clinical engagement event including learning from experiences of a wave 1 pilot site was useful and informative.

Triangle of Care There is training being provided to managers and matrons in November 2018 which will include the Secure Carers Toolkit, a nationally developed package to recognise the unique needs of carers for those in secure care.

Offender Health and Community We continue to work with partners to improve the services we deliver to our service users and are pleased that this work has been recognised with awards for:

Ref. PJB 12 Date:

 Integrated Support Unit at HMP Durham, recognising service improvement for improving the lives of offenders by the North Eastern Prison After Care Society (NEPACs).  The Ruth Cranfield Award - a member of the mental health team was highly commended by NEPACs for work with mentally ill offenders in the Care and Separation Unit.  Cleveland Liaison and Diversion services - Mental Health Emergency and Criminal Justice Award from the National Positive Practice Mental Health Collaborative.  The multi-agency perinatal team at HMP Low Newton – National Health and Safety Award, for the development of a maternity and perinatal pathway in a criminal justice setting.

We have submitted a tender bid for the 3 Liaison and Diversion services in Durham, Cleveland and North Yorkshire including a new potential service/business of North Yorkshire and await the outcome in December. We are preparing for the North East prisons tender commencing in April 2019. We have been approached for 2 new potential service developments, in HMP Preston and HMP Frankland to support mentally ill offenders, business cases are being developed for submission.

All 11 prisons within the North East and West have been accepted for the fourth cycle of the Quality Network for Prison Mental Health Network (Royal College of Psychiatrists). This includes completing peer network reviews within other national prisons and being peer reviewed. We view this as very positive in service improvement and sharing good practice.

4. IMPLICATIONS:

4.1 Compliance with the CQC Fundamental Standards: None

4.2 Financial/Value for Money: None

4.3 Legal and Constitutional (including the NHS Constitution): None

4.4 Equality and Diversity: None

4.5 Other implications: None

5. RISKS: None

6. CONCLUSIONS:

Ref. PJB 13 Date:

6.1 This paper provides a high level summary of some of the key service changes currently being managed.

7. RECOMMENDATION:

7.1 That the Council of Governors note the report and raise any questions they may have.

Ruth Hill Chief Operating Officer

Ref. PJB 14 Date:

ITEM NO. 12

FOR GENERAL RELEASE

COUNCIL OF GOVERNORS

DATE: 29th November 2018 TITLE: Quality Account Quarter 2 2018/2019 Performance Report REPORT OF: Sharon Pickering, Director of Planning, Performance & Communication Elizabeth Moody, Director of Nursing & Governance REPORT FOR: Assurance

This report supports the achievement of the following Strategic Goals: To provide excellent services working with the individuals users of our services  and their families to promote recovery and wellbeing To continuously improve the quality and value of our work  To recruit, develop and retain a skilled, compassionate and motivated workforce To have effective partnerships with local, national and international organisations for the benefit of the communities we serve To be recognised as an excellent and well governed Foundation Trust that  makes best use of its resources for the benefit of the communities we serve

Executive Summary:

This is the second progress report for the Quality Account during 2018/2019 covering the period July to September 2018 (Quarter 2).

This report presents updates against each of the current four Quality Account improvement priorities as well as performance against the clinical safety, effectiveness and experience metrics in TEWV’s Quality Account.

The delivery of the four key quality priorities for 2018/2018 is largely on track, with 87% of actions delivered on time, or expected to finish before a future deadline.

In terms of Quality Metrics, 3 of 9 (33%) are reporting green. We are reporting red on 6 of 9 metrics (66%).

TEWV has successfully applied for all 3 wards which serve children and young people at West Lane Hospital to take part in a National Service Improvement Project facilitated by NHS England and NHS improvement. This commenced on 23rd November. It is hoped that this will help TEWV to reduce the levels of restrictive intervention.

Recommendations:

Governors are asked to receive and comment on the progress made against the Quality Account priorities and metrics as at Quarter 2 2018/2019.

LK/CL 1 November 2018

MEETING OF: COUNCIL OF GOVERNORS DATE: 29th November 2018 TITLE: Quality Account 2018/2019 Quarter 2 Performance Report

1. INTRODUCTION AND PURPOSE

1.1 This is the second progress report for the TEWV Quality Account during 2018/2019 covering the period 1st July 2018 to 30th September 2018 (Quarter 2).

1.2 This report presents updates against each of the four key quality improvement priorities for 2018/2019 identified in the current Quality Account as well as performance against the agreed quality metrics.

2. BACKGROUND INFORMATION AND CONTEXT

2.1 NHS Trusts and Foundation Trusts are required to produce a quality account each year. The document must include between 3 and 5 quality priorities and a number of quality metrics (measures) and targets.

3. KEY ISSUES

3.1 Progress on the four Quality Priorities for 2018/2019

3.1.1 Within the 2017/2018 Quality Account the Trust agreed the following four quality improvement priorities for 2018/2019:

 Reduce the number of Preventable Deaths;  Improve the clinical effectiveness and patient experience in time of transition from Child to Adult services;  Make our Care Plans more personal;  Develop a Trust-wide approach to Dual Diagnosis, which ensures that people with substance misuse issues can access appropriate and effective mental health services.

3.1.2 There are a total of 46 actions set out in the Quality Account to deliver these priorities. 40 of these 46 quality improvement actions were Green at 30/09/2018 (87%). The paragraphs below shows that these are spread across all four priorities.

3.1.3 Actions that were reporting red at 30/09/2018 are set out below:

 Further Improve the clinical effectiveness and patient experience at times of transition from CYP to Adult services - Implement actions from the thematic review of patient stories: Although all patients who transition from CYP to Adult services are asked 3 months later to complete a post-transitions survey so far there have only been three responses received. There are actions in place to ensure transferees are better targeted; this is still work in progress but there is not enough data available to be able to complete a thematic review. It is expected that this will be delivered in Quarter 3 2018/2019 after we have collected more patient stories.

LK/CL 2 November 2018

 Improve the personalisation of care planning – Co-develop training and development packages and align to, and incorporate where possible, the training and development work of other programmes, projects and business as usual – these must include evaluation measures: The development of the training packages is currently underway but is not yet complete. They are being co-produced with the Trust’s Experts by Experience. It is expected that this will be now be delivered in Quarter 3 2018/2019.

 Develop a Trust-wide approach to Dual Diagnosis which ensure that people with substance misuse issues can access appropriate and effective mental health services – Directorates and specialties to confirm their use of Dual Diagnosis Clinical Link Pathway (CliP) within relevant pathways: The Dual Diagnosis Clinical Link Pathway has been circulated but all feedback has not yet been obtained from all parts of the Trust. It is expected that this will now be delivered in Quarter 3 2018/2019.

 Develop a Trust-wide approach to Dual Diagnosis which ensure that people with substance misuse issues can access appropriate and effective mental health services – To introduce a Training Needs Analysis (TNA) which includes dual diagnosis and identify those staff who have dual diagnosis capabilities: The Dual Diagnosis staff competency and training audit is currently in draft format however it is expected that this will be delivered in full in Quarter 3 2018/2019.

 Reduce the number of Preventable Deaths – To produce an engagement plan to involve family, carers and non-Executive Director within the review process: Guidance was published by the National Quality Board in late July. An initial paper was taken to Patient Safety Group in August. The resulting plan is being discussed by TEWV’s Patient Safety Group in October (just after the end of quarter 2 when this was due) and will be implemented by the end of Quarter 3 2018/2019.

3.2 Performance against Quality Metrics at Quarter 2

Our full Quality improvement metric performance is set out in Appendix 1. The following table shows the number and percentage of the Quality Metrics in each RAG Category as at Quarter 2. The RAG ratings used to monitor the metrics are simply green if the target is met and red if the target is not met.

RED GREEN Patient Safety Measures 67% 33% Clinical Effectiveness Measures 33% 67% Patient Experience Measures 100% 0%

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3.2.1 Patient Safety Measures – Information regarding Red metrics

Metric 1: Percentage of patients who report ‘yes, always’ to the question ‘Do you feel safe on the ward?’

The Trust position for Quarter 2 is 59.67%, which relates to 466 out of 781 surveys. This is 28.33% below the Trust target of 82.00% and represents reduction of just under 3 percentage points compared to the previous quarter. All localities are underperforming this quarter. North Yorkshire are performing highest with 70.48% and Forensic Services are performing lowest with 43.75%. Our data generally indicates that the most frequent reason that people feel unsafe is due to the presence / behaviour of other patients on the wards.

Metric 3: Number of incidents of physical intervention/restraint per 1000 occupied bed days

The Trust position for Quarter 2 is 34.43, which relates to 2,391 incidents out of 69,451 Occupied Bed Days (OBDs). This is 15.18 above the Trust target of 19.25 - almost identical to Q1. Forensic Services, North Yorkshire and Durham & Darlington are achieving the target this Quarter. Of the underperforming localities York & Selby had 30.89 incidents per 1000 OBDs and Teesside are performing furthest away from the target at 88.59 per 1000 OBDs. The Teesside figures are significantly higher than the rest of the organisation due to the frequency of incidents involving physical intervention that were reported from Trust’s West Lane Hospital.

West Lane is TEWV’s hospital for children and young people. This is located in Middlesbrough but admits patients from the whole of the North East and north Cumbria, and occasionally from elsewhere in the UK. 1,407 incidents were reported across the West Lane site during Q2. These incidents represent 59% of the Trust’s total usage of physical intervention. The majority of these incidents are linked to a small group of individuals, with 6 patients involved in 1,040 incidents. The complex needs of this group regularly require physical intervention to be utilised as part of their clinical treatment in providing them with nutrition. 2 of the 6 patients alone, due to the level and complexity of their needs, were involved in 531 of the reported incidents.

Services at West Lane continue to work closely with the Trust’s Positive and Safe team to develop Behaviour Support Plans for patients and to implement Safewards intervention access there wards. In addition to further support the wards, TEWV has successfully applied for all 3 wards at that hospital to take part in a National Service Improvement Project facilitated by NHS England and NHS improvement. This commenced on 23rd November. It is hoped that this will help TEWV to reduce the levels of restrictive intervention.

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3.2.2 Clinical Effectiveness Measures

Metric 6: Average length of stay for patients in Adult Mental Health Services and Mental Health Services for Older People Assessment and Treatment Wards:

The average length of stay for patients in Mental Health Services for Older People for Quarter 2 is 65.50 days. This is 13.5 above the Trust target of <52, and very similar to the Q1 position.

The median length of stay within MHSOP was 49 days, which is within the target threshold of less than 52 days and demonstrates that the small number of patients that had very long lengths of stay have a significant impact on the mean figures reported. The two drivers of long stays tend to be clinical complexity and a lack of suitable care home placements for patients to be discharged into. The Trust is engaging with some local authorities on locality specific schemes to reduce delayed discharges.

3.2.3 Patient Experience Measures

Metric 7: Percentage of patients who reported their overall experience as ‘excellent’ or ‘good’

The Trust position for Quarter 2 is 91.34%, which relates to 4,337 out of 4,748 surveys. This is 2.66% below the Trust target of 94.00%. There has been an improvement of just over half a percentage point from Q1 to Q2.

All localities are underperforming this quarter. North Yorkshire are performing highest with 93.38% and Forensic Services are performing lowest with 84.40%. There are a number of initiatives taking place which may improve patient experience. These include training forensic patients in quality improvement techniques and involving them in quality improvement work, rolling out recovery oriented practice, improving care planning and environmental improvements such as the creation of a family room at West Park Hospital, Darlington.

Metric 8: Percentage of patients that report that staff treated them with dignity and respect

The Trust position for Quarter 2 is 86.08%, which relates to 3,796 out of 4,410 surveyed. This is 7.92% below the Trust target of 94.00%, but represents an improvement of over 2 percentage points on Q1.

All localities are underperforming this quarter. North Yorkshire are performing highest with 89.74% and Forensic Services are performing lowest with 73.81%.

The Trust continues to communicate the need for managers and staff to reflect the Trust’s values in their day to day behaviours, and has been using expert by experience testimonies to increase both corporate and clinical staff understanding and empathy. The Trust is also delivering an autism awareness training programme

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so that staff can better understand how best to interact with, and take account of the needs of this particular service user group.

Metric 9: Percentage of patients that would recommend our service to friends and family if they needed similar care or treatment

The Trust position for Quarter 2 is 87.76%, which relates to 4,203 out of 4,789 surveys. This is 6.24% below the trust target of 94.00%, but is an improvement of just under 2 percentage points on Q1

All localities are underperforming this quarter. North Yorkshire are performing highest with 90.27% and Forensic Services are performing lowest with 81.20%

In relation to the Patient Experience Measures, the Trust is working hard to try and ensure that these targets are met in future. If there are areas/teams where specific issues are identified then action plans are put in place to address these. ep 4. IMPLICATIONS

4.1. Compliance with the CQC Fundamental Standards The information in this report highlights where we are not achieving the targets we agreed in our 2018/2019 Quality Account and where improvements are needed to ensure our services deliver high quality care and therefore meet the CQC fundamental standards.

4.2. Financial/Value for Money There are no direct financial implications associated with this report, however there may be some financial implications associated with improving performance where necessary. These will be identified as part of the action plans as appropriate.

4.3. Legal and Constitutional (including the NHS Constitution) There are no direct legal and constitutional implications associated with this paper, although the Trust is required each year to produce a Quality Account and this paper contributes to the development of this.

4.4. Equality and Diversity The Trust does monitor quality data for protected characteristic groups where possible, and takes action at Trust or Locality level to address issues as they are identified.

4.5. Risks There are no specific risks associated with this progress report

5. CONCLUSIONS

5.1 The current quality priorities are on track for delivery with only a few slight delays to specific actions.

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5.2 In terms of Quality Metrics, 3 of 9 (33%) are reporting green. We are reporting red on 6 of 9 metrics (66%). Although there have been some encouraging trends since the last quarter the issues that have to be addressed if the Trust is to hit its ambitious quality targets remain complex, and many of the initiatives we are taking will have an impact only in the long term. The national support being received at West Lane should help the Trust to reduce the instances of restraint.

6. RECOMMENDATIONS

6.1 Governors are asked to receive and comment on this report on the progress made against the Quality Account as at Quarter 2 2018/2019.

Chris Lanigan Head of Planning and Business Development

Laura Kirkbride Planning and Business Development Manager

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Appendix 1: Performance with Quality Metrics at Quarter 2 2018/2019

Quality Metrics Patient Safety Measures Quarter 1 18/19 Quarter 2 18/19 Quarter 3 18/19 18/19 2017/2018 2016/2017 2015/2016 Target Actual Target Actual Target Actual Target Actual 1: Percentage of patients who report ‘yes, always’ to the question ‘Do you feel safe on 88.00% 62.40% 88.00% 59.67% 88.00% 88.00% 62.30% N/A N/A the ward?’ 2: Number of incidents of falls (level 3 and above) per 1000 occupied bed days (OBDs) - 0.35 0.17 0.35 0.19 0.35 0.35 0.12 0.37 N/A for inpatients 3: Number of incidents of physical intervention/restraint 19.25 34.23 19.25 34.43 19.25 19.25 30.65 20.26 N/A per 1000 occupied bed days Clinical Effectiveness Measures 4: Existing percentage of patients on Care Program Approach who were followed up within 7 days after >95% 98.07% >95% 97.03% >95% >95% 94.78% 98.35% 97.75% discharge from psychiatric inpatient care 5: Percentage of clinical audits of NICE Guidance 100% 0% 100% 100% 100% 100% 100% 100% 100% completed 6a: Average length of stay for patients in Adult Mental

Health Assessment and <30.2 24.76 <30.2 21.73 <30.2 <30.2 27.64 30.08 26.81 Treatment Wards 6b: Average length of stay for patients in Mental Health Services for Older People <52 65.89 <52 65.50 <52 <52 67.42 78.08 62.67 Assessment and Treatment Wards

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Patient Experience Measures 7: Percentage of patients who reported their overall experience as excellent or 94.00% 90.82% 94.00% 91.34% 94.00% 94.00% 90.50% 90.53% N/A good 8: Percentage of patients that report that staff treated them with dignity and 94.00% 84.60% 94.00% 86.08% 94.00% 94.00% 85.90% N/A N/A respect 9: Percentage of patients that would recommend our service to friends and family 94.00% 85.81% 94.00% 87.76% 94.00% 94.00% 87.20% 86.58% 85.51% if they needed similar care or treatment

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Appendix 2: Performance against Quality Metrics by Locality

Durham & North Forensic York & Quality Metric Trust Teesside 1 Darlington Yorkshire Services Selby Metric 1: Percentage of patients who report ‘yes, always’ to the question ‘Do you feel safe 59.67% 64.06% 53.45% 70.48% 43.75% 60.56% on the ward?’ Metric 2: Number of incidents of falls (level 3 and above) per 1000 occupied bed days (OBDs) 0.19 0.24 0.17 0.31 0.00 0.49 - for inpatients Metric 3: Number of incidents of physical intervention/restraint per 1000 occupied bed 34.43 14.80 88.592 13.05 12.00 30.89 days Metric 4: Percentage of patients on Care Programme Approach who were followed up within 7 days after discharge from psychiatric 97.03% N/A N/A N/A N/A N/A inpatient care: Metric 5: Percentage of Clinical Audits of NICE Guidance completed: 100% N/A N/A N/A N/A N/A Metric 6a: Average length of stay for patients in Adult Mental Health Services Assessment and 21.73 N/A N/A N/A N/A N/A Treatment Wards: Metric 6b: Average length of stay for patients in Mental Health Services for Older People 65.50 N/A N/A N/A N/A N/A Assessment and Treatment Wards: Metric 7: Percentage of patients who reported their overall experience as ‘excellent’ or ‘good’ 91.34% 92.35% 91.09% 93.38% 84.40% 90.43% Metric 8: Percentage of patients that report that staff treated them with dignity and respect 86.08% 88.62% 84.34% 89.74% 73.81% 87.07% Metric 9: Percentage of patients that would recommend our service to friends and family if 87.76% 89.43% 87.14% 90.27% 81.20% 85.63% they needed similar care or treatment

1 Services covering Hambleton, Richmondshire, Whitby, Scarborough, Harrogate and Rural District and Ryedale. The Wetherby area of Leeds is also served by these teams. 2 Teesside statistics include the children and young people’s wards at West Lane, which serves the North East and north Cumbria (and also admits patients from Yorkshire and elsewhere)

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ITEM 13

FOR GENERAL RELEASE

BOARD OF DIRECTORS

DATE: 29th November 2018 TITLE: Board Dashboard as at 30th September 2018 REPORT OF: Sharon Pickering, Director of Planning, Performance & Communication REPORT FOR: Assurance

This report supports the achievement of the following Strategic Goals:  To provide excellent services working with the individual users of our services and their carers to promote recovery and wellbeing  To continuously improve to quality and value of our work  To recruit, develop and retain a skilled, compassionate and motivated  workforce To have effective partnerships with local, national and international organisations for the benefit of the communities we serve  To be recognised as an excellent and well governed Foundation Trust that makes best use of its resources for the benefits of the communities we serve. 

Executive Summary:

The purpose of this report is to provide the Council of Governors with the Board Dashboard as at 30th September 2018 (Appendix A) in order to inform them of the performance of the organisation against the KPIs within the Trust Dashboard.

As at the end of September 2018, 8 (47%) of the indicators reported are not achieving the expected levels and are red. This is the same position as at the end of August. 50% of these are within the ‘quality’ domain, however it should be noted that one of these (KPI 2) is new and has only recently been reported against. In addition there are 7 KPIs (41%) that whilst not achieving the target are within the ‘amber’ tolerance levels, which again is the same position as at the end August.

Of the 15 indicators that are either red or amber 7 (41%) are showing an improving trend over the previous 3 months.

The year to date position is that there are 8 KPIs (47%) which are reported as red which is the same position as at the end August.

In terms of the Single Oversight Framework targets the Trust achieved all the operational and quality targets in September and for Q2 as a whole, however there was variance in terms of achievement across the CCGs.

Recommendations: It is recommended that the Council of Governors receive this report for information.

MEETING OF: Council of Governors DATE: 30th October 2018 TITLE: Board Dashboard as at 30th September 2018

1. INTRODUCTION & PURPOSE:

1.1 To present to the Council of Governors the Trust Dashboard as at 30th September 2018 (Appendix A). Further detail for each indicator, including trends over the previous 3 years, will be available within the information pack available at the Council of Governors meeting or can be provided electronically on request from the Trust Secretary’s department [email protected] .

2. KEY ISSUES:

2.1 Performance Issues

The key issues in terms of the performance reported are as follows:

 As at the end of September 2018, 8 (47%) of the indicators reported are not achieving the expected levels and are red. This is the same position as at the end of August. 50% of these are within the ‘quality’ domain, however it should be noted that one of these KPI (KPI 2) is new and has only recently been reported against. In addition there are 7 KPIs (41%) that whilst not achieving the target are within the ‘amber’ tolerance levels, which again is the same position as at the end August.

Of the 15 indicators that are either red or amber 7 (41%) are showing an improving trend over the previous 3 months.

The year to date position is that there are 8 KPIs (47%) which are reported as red which is the same position as at the end August.

 In terms of the Single Oversight Framework targets the Trust achieved all the operational and quality targets in September and for Q2 as a whole. Specific issues are as follows: o The 7 day follow up following discharge was not achieved in 3 CCGs in September but there are no specific concerns in terms of trends. Indeed the target was achieved for Quarter 2 in all CCGs. o IAPT/Talking Therapies – “proportion of people completing treatment who move to recovery” – as a Trust performance was just at the target level for the Quarter as a consequence of low performance in the month of July. In terms of CCGs there were two CCGs were the target was not achieved in September (DDES CCG and Vale of York CCG). In terms of the Quarter 2 position we did not achieve the target in 3 CCGs (DDES, Vale of York and Hambleton, Richmondshire and Whitby CCGs). o Access to Early Intervention in Psychosis - the Trust as a whole significantly overachieved against the target in September and for Quarter 2 due to some strong performances across Durham,

Darlington and Teesside teams. However the North Yorkshire Services and York and Selby Services failed to achieve the target for Quarter 2 although the York and Selby service did achieve it in September unlike the North Yorkshire services. There has been particularly challenges regarding staffing across all these services however the York and Selby services have got new staff coming into post. o Inappropriate Out of Area Occupied Bed Days – the target was not achieved in 3 CCGs in September and Quarter 2.These all related to ‘Internal’ Out of Area admissions i.e. admissions within other areas of the Trust. There were no patients admitted externally from the Trust due to pressure on beds.

 Appendix C includes the breakdown of the actual number of unexpected deaths by month.

2.3 Key Risks

 Waiting times (KPI 1 and 2) – The %age patients sees within 4 weeks of Referral (KPI1) has seen a deteriorating position since May 2018 mainly as a consequence of low performance in North Yorkshire and York and Selby localities. Whilst KPI2 (waiting times for treatment) is a new indicator and as such focus is now being given to it there is a risk that if KPI 1 shows a deteriorating position then this will have a negative impact on delivery of the waiting time to treatment as well.

 Bed Occupancy (KPI 12) – The pressures on beds has continued in September with occupancy levels remaining similar to those in August. There has been a slight improvement in the % of patient readmitted within 30 days and the number of inappropriate Out of Area days however the number of patients with a length of stay greater than 90 has remain slightly above target. All localities are monitoring bed occupancy daily and are ensuring that admissions over 30 day length of stay are reviewed to ensure they remain appropriate or if further action is required to support discharge however there are a number of complex patients on the wards who do required longer lengths of stay. In addition within North Yorkshire and York there are a number of patients whose discharge is delayed as no suitable placement has been identified.

 Number of Unexpected Deaths Classed as a Serious Incident (KPI 5) – Whilst the rate per 10,000 open cases improved in September it still remains above target and the absolute number was the same as in August.

 Outcome Indicators (KPIs 6 and 7) – Performance against the two outcome indicators (clinically reported (HONOS) and patient reported (SWEMWEBS)) continues to be considerably worse than target. The PBR team continue to share reports with services to allow them to focus on the reasons for the ‘breaches’ and work is being undertaken in all localities on reemphasising the need to record outcome scores in order to be able to

demonstrate improvement made. Following the Performance Improvement Group in May, chaired by the COO, a further discussion was held at the October PIG meeting regarding how we can improve the recording of outcome scores. A number of actions were agreed including gaining an understanding of the variation in where outcomes have not been recorded due to it not being clinically appropriate; a review by the Service Development Groups of the validity of the outcomes being used and ensuring that the presentation of the data is improved to support and understanding of the positon and a focus in terms of action.

 Sickness Absence Rate (KPI 19) – whilst performance has improved in the position reported in September (August sickness) it is still at one of the highest position for the year to date (although it is still better than the position reported in September 2017). A review of the Trusts approach to managing sickness absence is underway and it is expected that a new procedure will be available in the coming months. The main outliers are Forensic and Durham and Darlington.

 Financial Targets (KPIs 21) – In the month of September (and Year to Date) we have not achieved the target for CRES delivery although an improvement has been seen over the past few months. Work is ongoing via the Programme Board to identify further recurrent CRES schemes and it is expected that the target will be achieved by the year end.

2.4 Appendix B provides the data quality scorecard.

2.4 Appendix C provides further details of unexpected deaths including a breakdown by locality.

2.5 Appendix D provides a glossary of indicators.

3. RECOMMENDATIONS:

It is recommended that the Council of Governors receive this paper for information

Sharon Pickering Director of Planning, Performance and Communications

Appendix A Trust Dashboard Summary for TRUST

Quality

September 2018 April 2018 To September 2018 Annual Target Month Status Trend Arrow (3 Target YTD Status Target Months) 1) Percentage of patients who were seen within 4 weeks for a first appointment following an 90.00% 85.79% 90.00% 86.98% 90.00% external referral 2) Percentage of patients starting treatment within 6 weeks of an external referral 60.00% 41.62% 60.00% 28.29% 60.00%

3) The total number of inappropriate OAP days over the reporting period (rolling 3 months) 2,389.00 2,080.00 2,389.00 2,080.00 2,389.00

4) Percentage of patients surveyed reporting their overall experience as excellent or good 92.45% 92.01% 92.45% 91.05% 92.45%

5) Number of unexpected deaths classed as a serious incident per 10,000 open cases - Post 1.00 1.26 6.00 9.21 12.00 Validated 6) The percentage of in scope teams achieving the agreed improvement benchmarks for HoNOS 67.25% 55.29% 67.25% 55.93% 67.25% total score (AMH and MHSOP) - month behind 7) The percentage of in scope teams achieving the agreed improvement benchmarks for 78.25% 67.90% 78.25% 65.12% 78.25% SWEMWBS total score (AMH and MHSOP) - month behind Activity

September 2018 April 2018 To September 2018 Annual Target Month Status Trend Arrow (3 Target YTD Status Target Months) 12) Bed Occupancy (AMH & MHSOP Assessment & Treatment Wards) 85.00% 94.17% 85.00% 94.96% 85.00%

13) Number of patients occupying a bed with a length of stay (from admission) greater than 90 68.00 73.00 68.00 73.00 68.00 days (AMH and MHSOP A&T Wards) 14) Percentage of patients re-admitted to Assessment & Treatment wards within 30 days 23.93% 24.14% 23.93% 21.97% 23.93% (AMH & MHSOP) - in reporting month Workforce Appendix A Trust Dashboard Summary for TRUST

September 2018 April 2018 To September 2018 Annual Target Month Status Trend Arrow (3 Target YTD Status Target Months) 15) Actual number of workforce in month (Establishment 95%-100%) 95.00% 92.32% 95.00% 92.32% 95.00%

16) Vacancy fill rate 90.00% 76.29% 90.00% 76.07% 90.00%

17) Percentage of staff in post more than 12 months with a current appraisal (snapshot) 95.00% 90.40% 95.00% 90.40% 95.00%

18) Percentage compliance with ALL mandatory and statutory training (snapshot) 92.00% 90.11% 92.00% 90.11% 92.00%

19) Percentage Sickness Absence Rate (month behind) 4.50% 4.90% 4.50% 4.81% 4.50%

Money

September 2018 April 2018 To September 2018 Annual Target Month Status Trend Arrow (3 Target YTD Status Target Months) 20) Delivery of our financial plan (I and E) -648,000.00 -845,476.00 -3,486,000.00 -3,699,446.00 -6,864,000.00

21) CRES delivery 686,782.00 532,724.00 4,120,692.00 3,126,654.00 8,241,384.00

22) Cash against plan 66,684,000.00 68,362,000.00 66,684,000.00 68,362,000.00 56,640,000.00 Data Quality Scorecard 2018/19 Appendix B

KPI Data Source Data Reliability KPI Construct/Definition amended/ Tested A (5) B (4) C (3) D (2) E (1) 5 4 3 2 1 5 4 3 2 1 Data KPI requires extracted testing - Total Direct Percentage Notes from Access KPI is defined KPI is defined KPI programmed Score Electronic Other Paper or KPI is Electronic database or Always Mostly Sometimes Untested but could be but is clearly construction KPI is not test date transfer Provider telephone Unreliable clearly Y/N System but Excel reliable reliable reliable Source open to open to is not clearly defined from System collection defined data is then Spreadsheet interpretation interpretation defined System processed manually 1 Pergentage of patients who were seen within 4 weeks for a first appointment 555Y15100% following an external referral 3 Total number of inappropriate OAP days Data is extracted electronically, validated manually and reuploaded over the reporting period 45 5 Y1493% into the system. Work is underway to amend PARIS to enable this (rolling 3 months) to be recrrded completely on the system.

4 Percentage of patients surveyed reporting their Patient and carer experience feedback is managed by the PaCE overall experience as Team supported by the Meridian system, provided by an external excellent or good. provider; Optimum Contact. The system was implemented trustwide on 1 April 2017. Data is collected via electronic devices for 25 5 Y1280% inpatient areas, on paper surveys for community teams as well as via kiosks in team bases where there are large footfalls. There is also a phone Application now where clinicians can send the survey to patients and carers phones via email or SMS. The Data Quality Team access the system to generate reports.

5 Number of unexpected deaths classed as a Data will be directly extracted from Datix into the IIC; however, this serious incident per 10,000 Not process is not fully embedded. IAPT caseload is currently a manual open cases required - upload. 45 5 14 93% manual return Data reliability has improved following the introduction of the central approval team

6 The percentage of teams achieving the agreed improvement benchmarks Data is extracted electronically and then processed 445 Y1387% for HoNOS total score manually. Work is underway with the services to ensure the data recorded on PARIS is accurate and this will improve data reliability. 7 The percentage of teams achieving the agreed Data is extracted electronically and then processed improvement benchmarks 445 Y1387% manually. Work is underway with the services to ensure the for SWEMWBS total score data recorded on PARIS is accurate and this will improve data reliability. 12 Bed Occupancy (AMH & MHSOP A&T wards)

555Y15100%

13 Number of patients occupying a bed with a length of stay (from admission) greater than 90 days (AMH & MHSOP A&T Wards) 555Y15100%

14 Percentage of patients readmitted to Assesement and treatment wards within 30 days 555Y15100% Data Quality Scorecard 2018/19

45 5 Y1493% Data extracted elecronically but processed manually

16 Vacancy Fill rate

Not required - Data recorded on the recruitment tracker database and manually 25 5 12 80% manual uploaded into the system return

17 Percentage of staff in post more than 12 months with a current appraisal Issues with appraisal dates being entered to ESR have lessened 5 45 Y1493% considerably. Compliance levels are effectively being monitored via monthly Huddle meetings. There feels to be greater confidence in the data being reported through IIC.

18 Percentage compliance with ALL mandatory and statutory training 5 45 Y1493% Issues with training compliance figures being reported have lessened - there appears to be greater confidence in the data being reported.

19 Percentage Sickness Absence Rate (month behind) Whilst the sickness absence data for inpatient services is now being taken directly from the rostering system which should help to To be agreed eliminate inaccuracies the remainder of the Trust continue to input in Managing directly into ESR. There are some data quality issues concerned 5 45 N14 93% Business Sub with failing to end sickness in a timely manner– this is picked up group and monitored through sickness absence audits that the Operational HR team undertake.

20 Delivery of our financial plan (I and E)

Not required - 45 5 14 93% manual return

Data is collected on Excel with input co-ordinated and controlled by the Financial Controller and version control in operation. 21 CRES Delivery Not required - 25 5 12 80% manual Data is collected on Excel with input co-ordinated and controlled by return the Financial Controller and version control in operation. 22 Cash against plan Not required - 45 5 14 93% manual An extract is taken from the system then processed manually to return obtain actual performance. Appendix C

Number of unexpected deaths and verdicts from the Coroner April 2018 - March 2019

Number of unexpected deaths classed as a serious untoward incident Number of unexpected deaths total by locality Durham & North York & April May June July August September October November December January February March Teesside Forensics Darlington Yorkshire Selby 10 4 14 15 9 9 000000 22 13 15 4 7

Number of unexpected deaths and verdicts from the Coroner April 2017 - March 2018

Number of unexpected deaths and verdicts from the Coroner 2016 / 2017 This table has been included into this appendix for comparitive purposes only

Y&S recorded in old Datix not included Appendix D Trust Dashboard 2018/19

KPI Guide

KPI Target Definition

1 Percentage of 90% This measures, the number of patients who attend their first patients who were appointment in 4 weeks of their referral date out of the total seen within 4 weeks number of people who attend their first appointment following for a first appointment their referral. following an external referral This KPI has been amended for 2018/19 and the clock will now NOT restart if the patient DNAs or the patient cancels an appointment.

This looks at patients with an external referral only.

This Excludes IAPT patients.

2 Percentage of TBC This measures, the number of people starting treatment within 6 patients starting weeks of an external referral against number of people starting “treatment” within 6 treatment. weeks of external referral This looks at patients with an external referral only. 3 The total number of 2,494 This measures, the total number of days patients have spent in inappropriate OAP an out of area bed inappropriately. In line with national reporting days over the this measures a rolling 3 months time frame reporting period (Rolling 3 months) 4 Percentage of 92.45% Within all inpatient and community services, this measures: patients surveyed Of the number of people in the Patient Survey who answered the reporting their overall question: - "Overall how would you rate the care you have experience as received?,” the number of patients who have scored "excellent" excellent or good or "good".

5 Number of 12 This measure looks at the number of unexpected deaths classed unexpected deaths as a serious incident per 10,000 open cases. classed as a serious incident per 10,000 This mirrors the data that is reported to the National Reporting open cases and Learning System (NRLS) 6 The % teams 67.25% This measure relates to patients discharged from TEWV In achieving the agreed Scope services (Spells ended with a Adult or MHSOP subject to improvement Currency & Tariff National requirements). benchmarks for HoNOS total score Patients total HoNOS scores are compared from the first rating against the last. A reduction in total HoNOS score is classified as improvement. 80% of patients in the Non Psychotic and Psychotic superclass and 40% in the organic superclass are expected to achieve this reduction. Teams are subject to the measure if they discharge more than 5 patients in any of the superclasses. The measure will report against the team the patient was with at the point they are discharged entirely from TEWV not if they are transferred to a different In Scope team. Trust Dashboard 2018/19

KPI Guide

7 The % teams 78.25% This measure relates to patients discharged from TEWV In achieving the agreed Scope services (Spells ended with a Adult or MHSOP subject to improvement Currency & Tariff National requirements). benchmarks for

SWEMWBS Patients total SWEMWBS scores are compared from the first rating against the last. An increase in SWEMWBS score is classified as improvement. 80% of patients in the Non Psychotic and Psychotic superclass and 50% in the organic superclass are expected to achieve this reduction. Teams are subject to the measure if they discharge more than 5 patients in any of the superclasses. The measure will report against the team the patient was with at the point they are discharged entirely from TEWV not if they are transferred to a different In Scope team.

8 Number of new TBC This measures the number of new individual patients referred ie unique patients a patient is only counted once. This is when the patient is not referred open to any other team in the Trust.

This Excludes IAPT patients.

9 The number of TBC This measures the number of all external referrals into Trust with external referrals with an assessment completed an Assessment completed This Excludes IAPT patients.

10 The number of TBC This measures all external referrals to all services that have been external referrals accepted onto teams caseload. which were subsequently This Excludes IAPT patients. accepted onto caseload 11 The number of TBC This measures all discharges excluding discharges from total  Patients who were not appropriate to accept onto caseload caseload  Patients who had a referral closed without being seen  Patients who were assessed but not offered treatment.  IAPT patients. 12 Bed Occupancy (AMH 85% This measures the number of days beds that are occupied out of & MHSOP A & T the number of possible bed days available. (The calculation is Wards) on the number of beds available and the days in the month).

This looks at AMH and MHSOP Assessment and Treatment wards only 13 Number of patients 68 This measures the number of patients occupying a bed with a occupying a bed with length of stay longer than 90 days from the day they were a length of stay (from admitted. admission) greater than 90 days (AMH & This looks at AMH and MHSOP Assessment and Treatment MHSOP A&T Wards wards only (Snapshot) Trust Dashboard 2018/19

KPI Guide

14 Percentage of TBC This measures the number of patients who are readmitted onto a patients re-admitted ward within 30 days of their last discharge. to Assessment & This looks at AMH and MHSOP Assessment and Treatment Treatment wards wards only within 30 days (AMH & MHSOP) 15 Actual number of 95% This measures the total number of contracted staff against the workforce in month number of budgeted staff.

16 Vacancy fill rate 90% This measures the number of vacancies where an offer of employment has been made out of the number of vacancies that are being recruited to.

There are vacancies that have been advertised and not filled due to no applicants or no one shortlisted, however from a recruitment vacancy perspective are closed off as an episode – These are not included in the figures as they do not go over the 8 week time frame.

This looks at posts that have been vacant longer than 8 weeks.

This KPI will exclude bank staff and only include professional health care posts of Band 5 and above 17 Percentage of staff in 95% This measures the number of staff in post more than 12 months post more than 12 and of those how many have a current appraisal. months with a current appraisal For medical staff this is monitored against 13 months.

18 Percentage 92% This measures the total number of courses completed by each compliance with ALL member of staff for ALL mandatory and statutory training out of mandatory and the number of courses due to be completed for each member of statutory training staff 19 Percentage Sickness 4.50% This measures the number of days lost to sickness out of the Absence Rate number of days within the month

20 Delivery of our - This shows the Trusts surplus or deficit position (£). The target is financial plan (I&E) 8556,000 the planned surplus position.

21 CRES delivery 8,241,384 This shows the CRES Identified against the planned amount

22 Cash against plan 56,640 This shows the actual cash held by the Trust against the amount of cash forecasted to be held

Item 14 FOR GENERAL RELEASE COUNCIL OF GOVERNORS

DATE: 29th November 2018 TITLE: Finance Report for Period 1 April 2018 to 30 September 2018 REPORT OF: Patrick McGahon, Director of Finance and Information REPORT FOR: Assurance and Information

This report supports the achievement of the following Strategic Goals:  To provide excellent services working with the individual users of our services and their carers to promote recovery and wellbeing To continuously improve to quality and value of our work To recruit, develop and retain a skilled, compassionate and motivated workforce To have effective partnerships with local, national and international organisations for the benefit of the communities we serve To be recognised as an excellent and well governed Foundation Trust that  makes best use of its resources for the benefits of the communities we serve.

Executive Summary:

The comprehensive income outturn for the period ending 30 September 2018 is a surplus of £3,698k, representing 2.2% of the Trust’s turnover and is £212k ahead of plan.

Performance Against Plan – year to date (3.2)

Monthly Variance Movement Movement The Trust is currently £212k ahead of its year to date financial plan. £000 £000 -212 -196

Cash Releasing Efficiency Savings (CRES) (3.3)

Annual CRES Type Variance Movement Identified CRES schemes for the £000 financial year are £296k behind Recurrent 4,607 financial plan. Non recurrent -4,311 Target 0 Variance 296

Identified CRES schemes for the rolling Annual CRES Type Variance Movement 3 year period are £15,214k the behind £000 £21,000k CRES target. Recurrent 15,214

A Waste Reduction Programme has been established to assist the Trust in delivering the recurrent CRES requirements in full, and a 3 year CRES plan.

1 Capital (3.4)

Monthly Variance The Trust is currently £1,243k in Movement Movement excess of its capital plan. £000 £000 1,243 947

The Trust received a capital rebate relating to prior year schemes (£2,289k), with this included, capital expenditure is £1,046k behind plan.

Workforce (3.5)

Variance Movement The Trust is currently £1,298k (45%) Movement £000 £000 in excess of its agency cap. 1,298 378

Agency expenditure remains high in month 6 across all localities and is largely required for nursing agency to support enhanced observations with complex clients.

Use of Resources Risk Rating (UoRR) (3.7)

Plan Actual Movement The Trust is currently behind its planned UoRR which is rated 1 to 4 with 1 being 12 good. The Trust is forecasting to be its behind 1 2 planned UoRR at the financial year end.

The Trust is forecasting to be behind plan due to agency expenditure being in excess of the capped target.

Recommendations:

The Council of Governors is requested to receive the report, to note the conclusions in section 6 and to raise any issues of concern, clarification or interest.

2 MEETING OF: Council of Governors DATE: 29 November 2018 TITLE: Finance Report for Period 1 April 2018 to 30 September 2018

1. INTRODUCTION & PURPOSE:

This report sets out the financial position for 1 April 2018 to 30 September 2018.

2. BACKGROUND INFORMATION AND CONTEXT:

2.1 This report will enable the Council of Governors to monitor the Trust’s key financial duties and performance indicators which are both statutory requirements.

2.2 NHS Improvement’s Use of Resources Rating (UORR) evaluates Trusts based on ability to service debt, liquidity, I&E margin, achievement of planned I&E margin and agency expenditure.

3. KEY ISSUES:

3.1 Key Performance Indicators

The Trust is achieving the control total set by NHSI, the Use of Resources Rating for the Trust is behind plan due to agency expenditure exceeding the capped target. The amount of CRES identified is marginally below required levels, and actions taken to rectify are detailed in section 3.3.

3.2 Statement of Comprehensive Income

The comprehensive income outturn for the period ending 30 September 2018 is a surplus of £3,698k, representing 2.2% of the Trust’s turnover and is £212k ahead of plan.

Table 1 Year to Date Year to Date YTD Annual Plan Plan Actual Variance £000 £000 £000 £000 Income From Activities (332,904) (163,331) (163,021) 310 Other Operating Income (16,751) (9,165) (9,279) (114) Total Income (349,655) (172,496) (172,301) 195 Pay Expenditure 262,892 131,444 130,907 (537) Non Pay Expenditure 68,582 31,912 32,186 274 Depreciation and Financing 11,317 5,655 5,509 (145) Variance from plan (6,864) (3,486) (3,698) (212)

3.3 Cash Releasing Efficiency Savings (CRES)

The Trust’s performance against the 2018/19 CRES target is shown in table 2 below. The Trust is behind plan (£296k) and continues to identify schemes to ensure full delivery of recurrent CRES requirements.

3 Table 2 Annual CRES Type Variance Movement £000 Identified CRES schemes for the Recurrent 4,607 financial year are £296k behind Non recurrent -4,311 financial plan. Target 0 Variance 296

3.4 Capital

Expenditure against the capital programme to 30 September 2018 is £5,966k and is £1,243k in excess of plan largely due to expenditure incurred on the Roseberry Park MIST system being offset by delays on the York and Selby Inpatient facility.

The Trust received a capital rebate relating to prior year schemes (£2,289k), with this included, capital expenditure is £1,046k behind plan.

3.5 Workforce

Table 3 below shows the Trust’s performance on some of the key financial drivers identified by the Board.

Table 3 Pay Expenditure as a % of Pay Budgets Tolerance Tolerance Apr May Jun Jul Aug Sep Sep-18 Establishment (a) (90%-95%) 92.3% 94.60% 93.70% 93.41% 92.77% 92.72% 92.31% Agency (b) 1.0% 2.70% 2.80% 2.80% 2.98% 3.05% 3.19% Overtime (c) 1.0% 1.60% 1.20% 1.12% 1.12% 1.13% 1.11% Bank & ASH (flexed against 5.7% 3.30% 2.90% 3.08% 2.93% 2.98% 3.09% establishment) (100%-a-b-c) Total 100.0% 102.20% 100.60% 100.41% 99.80% 99.88% 99.70%

The tolerances for flexible staffing expenditure are set at 1% of pay budgets for agency and overtime, and flexed in correlation to staff in post for bank and additional standard hours (ASH). For September 2018 the tolerance for Bank and ASH is 5.7% of pay budgets.

NHS Improvement monitors agency expenditure against a capped target. Agency expenditure at 30 September 2018 is £4,193k which is £1,298k (45%) in excess of the agreed year to date capped target of £2,895k. Recruitment options are being explored to reduce dependency on agency, and progress continues to inform conversations with NHSI.

3.6 Cash

Total cash at 30 September 2018 is £68,362k, and is £228k higher than planned, largely due to working capital variations.

4 3.7 Use of Resources Risk Rating (UoRR) and Indicators

3.7.1 The Use of Resources Rating for the Trust is assessed as 2 for the period ending 30 September 2018 and is behind plan (table 4). Agency expenditure increased again in September which is higher than anticipated and in excess of the NHSI capped target. Work is on-going; and continues to be monitored, in order to improve this position.

Table 4 - Use of Resource Rating at 30 September 2018

NHS Improvement's Rating Guide Weighting Rating Categories % 1234 Capital service Cover 20 >2.50 1.75 1.25 <1.25 Liquidity 20 >0 -7.0 -14.0 <-14.0 I&E margin 20 >1% 0% -1% <=-1% I&E margin distance from plan 20 >=0% -1% -2% <=-2% Agency expenditure 20 <=0% -25% -50% >50%

TEWV PerformanceActual YTD Plan RAG Achieved Rating Planned Rating Rating Capital service cover 1.41x 3 1.43x 3 Liquidity 50.4 days 1 52.8 days 1 I&E margin 2.2% 1 2.1% 1 I&E margin distance from plan 0.1% 1 0.0% 1 Agency expenditure £4,193k 3 £2,895k 1

Overall Use of Resource Rating 2 1

3.7.2 The capital service capacity rating assesses the level of operating surplus generated, to ensure Trusts are able to cover all debt repayments due in the reporting period. The Trust has a capital service capacity of 1.41x (can cover debt payments due 1.41 times), which is marginally behind plan and rated as a 3. This rating is in line with the plan for quarter 2.

3.7.3 The liquidity metric assesses the number of days operating expenditure held in working capital (current assets less current liabilities). The Trust liquidity metric is 50.4 days; this is marginally behind plan and is rated as a 1.

3.7.4 The income and expenditure (I&E) margin assesses the level of surplus or deficit against turnover, excluding exceptional items e.g. impairments. The Trust has an I&E margin of 2.2% and is rated as a 1, which is in line with plan.

3.7.5 The I&E margin distance from plan ratio assesses the I&E Margin against plan, excluding STF income. The Trust I&E margin distance from plan is 0.1% which is ahead of plan and is rated as a 1.

3.7.6 The agency rating assesses agency expenditure against a capped target for the Trust. Agency expenditure is higher than the capped target and is rated as a 3.

The margins on Use of Resource Rating are as follows:

 Capital service cover - to improve to a 2 a surplus increase of £2,254k is required.

5  Liquidity - to reduce to a 2 a working capital reduction of £44,917k is required.  I&E Margin – to reduce to a 2 an operating surplus decrease of £1,931k is required.  I&E margin distance from plan – to reduce to a 2 an operating surplus decrease of £80k is required.  Agency Cap rating – to improve to a 2 a reduction in agency expenditure of £575k is required.

4. IMPLICATIONS: 4.1 There are no direct CQC, quality, legal or equality and diversity implications associated with this paper.

5. RISKS: 5.1 There are no risks arising from the implications identified in section 4.

6. CONCLUSIONS: 6.1 At the end of September the Trust is £212k ahead of the control total set by NHSI.

6.2 The amount of CRES identified for the financial year and rolling 3 year period is below required levels; however, the Trust continues to identify schemes to ensure full delivery of recurrent CRES requirements.

6.3 The Use of Resources Rating for the Trust is assessed as 2 for the period ending 30 September 2018 and is behind plan. The Trust is forecasting a rating of 2 at the end of the financial year which is behind plan due to the agency expenditure rating.

7. RECOMMENDATIONS: 7.1 The Council of Governors is requested to receive the report, to note the conclusions in section 6 and to raise any issues of concern, clarification or interest.

Patrick McGahon Director of Finance and Information

ITEM NO. 16 FOR GENERAL RELEASE COUNCIL OF GOVERNORS

DATE: 29 NOVEMBER 2018

TITLE: Involvement of Service Users and Carers REPORT OF: Task and Finish Group – Involvement of Service Users and Carers REPORT FOR: Approval

This report supports the achievement of the following Strategic Goals:  To provide excellent services working with the individual users of our services  and their families to promote recovery and wellbeing To continuously improve the quality and value of our work  To recruit, develop and retain a skilled, compassionate and motivated  workforce To have effective partnerships with local, national and international organisations for the benefit of the communities we serve To be recognised as an excellent and well governed Foundation Trust that  makes best use of its resources for the benefit of the communities we serve.

Executive Summary: This report presents the findings and recommendations of the Task and Finish Group – Involvement of Service Users and Carers.

This review was prompted by issues raised by Governors when looking at how the Trust demonstrated meaningful service user and carer involvement and the perceived inconsistencies.

The review considered what involvement was underway in terms of meeting / governance and involvement groups and identified a number of gaps. Research was conducted through the interviewing of a range of individuals including those coordinating and undertaking involvement activities and senior management. It was concluded that that there was a significant amount of involvement underway within the Trust but there was clear inconsistencies and lack of awareness of roles of different staff and the different routes used to coordinate involvement.

It was considered that there was no single solution to the issues that were identified but there were a number of areas of best practice that demonstrated greater input into service design and delivery and a more valued and meaningful experience of those service users and carers participating. The Group has therefore identified a number of recommendations which the Trust could take to support and develop meaningful involvement of service users and carers in Trust activities and services.

Recommendations: To approve the recommendations that are contained within the summary report of the Task and Finish Group which can be found at Appendix 1 to this report.

Ref. KO 1 Date: 8/11/18

MEETING OF: Council of Governors DATE: 29 November 2018 TITLE: Involvement of Service Users and Carers

1. INTRODUCTION & PURPOSE:

1.1 The purpose of this report is to: a) Report the findings of the Task and Finish Group: Involvement of Service Users and Carers. b) Seek the Council of Governors’ support for the recommendations made by the Task and Finish Group.

2. BACKGROUND INFORMATION AND CONTEXT:

2.1 Service user and carer involvement within health and social care is a key element of a number of national policies and strategies:

 NHS England sets out its “ambition of strengthening participation in all of our work” and pledges to “work in partnership with patients and the public, to improve patient safety, patient experience and health outcomes; supporting people to live healthier lives.”  The NHS Constitution for England, outlines a number of patient rights and responsibilities.  NHS England’s Five Year Forward View advocates involving communities and citizens “directly in decisions about the future of health care services”.  Health and Social Care Act 2012

2.2 Within Tees, Esk and Wear Valleys NHS Foundation Trust, there are a number of Frameworks and Strategies that seek to be inclusive in terms of the involvement and engagement of service users and carers:

 Involvement and Engagement Framework  Recovery Strategy  Research and Development  Quality Strategy  Volunteer Strategy  Medical Development and Education  Compliance through inspection processes  Public Membership

2.3 The ongoing requirement to improve services and move to a more co- production model is high on the agenda for the Trust and this has been recognised by Governors through consideration of the Ladder of Participation. The views, feedback and experiences of Governors, service users, carers and staff in relation to service user and carer involvement in a variety of different types of activities demonstrated clear inconsistencies and experiences.

Ref. KO 2 Date: 8/11/18

2.4 Examples of differences with service user and carer involvement include those around major developments – York inpatient services versus Harrogate hospital and how different the involvement of service users and carers was undertaken. This was one of the key factors in driving this review to be undertaken in terms of major service re-design.

2.5 Inconsistency around the involvement of service users and carers within interview panels was also a consideration to take forward this review.

2.6 The Council of Governors, at its meeting on 17 November 2016, agreed to the establishment of a Task and Finish Group to review service user and carer involvement in the Trust (minute 16/92 refers).

2.7 The membership of the Task and Finish Group consisted of:

Chair Dr Hugh Griffiths, Non Executive Director Sponsor Catherine Haigh (tenure now ended) Members Cllr Ann McCoy, Mary Booth, Gary Matfin (tenure now ended), Dr Lakkur Murthy (tenure now ended), Dr Martin Combs (tenure now ended), Lisa Pope, Sarah Talbot-Landon

Mr Phil Bellas, Trust Secretary and Mrs Kathryn Ord, Deputy Trust Secretary supported and contributed to the work of the Group.

2.8 Meetings of the Group were held between April 2017 and June 2018.

2.9 In reviewing the involvement of service users and carers in the Trust the following was methodology was undertaken:

 A review conducted of the current routes of involvement for service users and carers within the Trust  An understanding where the ‘gaps’ were around involvement (data taken from Involvement and Engagement Team and appointments to governance groups)  A number of expert interviews held with: o Recovery Experts by Experience o Service Users o Carers o Directors of Operations o Involvement and Engagement Officers

2.10 The agreed scoping document is attached at Appendix 2 of this report.

3. KEY ISSUES:

3.1 The report of the Group including its recommendations is attached as Appendix 1 to this report.

Ref. KO 3 Date: 8/11/18

3.2 During the time duration of the conclusion of the meetings of the Task and Finish Group and the agreement of the recommendations to be put forward to the Council of Governors the Trust has:

 Taken the decision to merge the localities of North Yorkshire and York and Selby  Requested that all departments consider how they can make Cash Releasing Efficiency Savings (CRES)

3.3 As a result of 3.2 above, the Trust Secretary’s Department is required to consider how the merged locality can be supported by Involvement and Engagement Officer establishment in the future, whilst at the same time reducing its costs.

3.4 The Council of Governors is asked to approve the recommendations arising from the review taking into account that the operational locality structure has now changed since the recommendations were agreed by the Task and Finish Group.

4. IMPLICATIONS:

4.1 Compliance with the CQC Fundamental Standards: No risks identified, demonstrable involvement of service users and carers is undertaken by the Trust.

4.2 Financial/Value for Money: The recommendation to provide an annual event of celebration would require investment from the Trust.

The inequality of the involvement and engagement officer establishment across the Trust would need to await the outcome of organisational change linked to the merger of North Yorkshire and York and Selby locality and CRES outcomes.

4.3 Legal and Constitutional (including the NHS Constitution): No risks identified.

4.4 Equality and Diversity: No risks identified.

4.4 Other implications: Detailed at 4.2 above.

5. RISKS: No risks identified.

6. CONCLUSIONS:

6.1 It is considered that the Group has met its objectives and that its findings and recommendations will improve the involvement of service users and carers within the Trust.

Ref. KO 4 Date: 8/11/18

7. RECOMMENDATIONS: a) Approve the recommendations arising from the review as contained in Appendix 1 to this report.

Dr Hugh Griffiths Non Executive Director

Background Papers: Recommendations and Findings of the Task and Finish Group – Appendix 1 Research papers as contained in the Scoping Document – Appendix 2 Meeting papers and notes of Task and Finish Group : Involvement of service users and carers SWOT analysis of findings Appendix 1, Annex 1)

Ref. KO 5 Date: 8/11/18 Appendix 1

Summary Report and Recommendations

Council of Governors’ Task and Finish Group - Involvement

1 Introduction

This report sets out the findings and recommendations of a Task and Finish group review of service user and carer involvement within the Trust.

This review was prompted by issues raised by Governors when looking at how the Trust demonstrates service user and carer involvement which is a key element of a number of national policies and strategies.

2. Scope and Terms of Reference of the Review

The Council of Governors established the Task and Finish group to present a report recommending actions that the Trust could consider to improve how it involves service users and carers. The specific tasks were set out as below:

1) Research how the Trust seeks to involve service users and carers. 2) Identify any reporting mechanisms of the involvement of service users and carers. 3) Review how service users and carers are selected for involvement activities and where these are drawn from. 4) Review how service users and carers are involved in major developments within the Trust. 5) Review how service users and carers are involved in recruitment of staff within the Trust. 6) Review how service users and carers are involved in service improvements within the Trust. 7) Identify and recommend best practice for the meaningful involvement of service users in 3, 4, 5 and 6 above. 8) Recommend appropriate monitoring and reporting processes for the involvement of service users and carers.

3. Membership of the Task and Finish Group

The review was undertaken by:

Mr Phil Bellas, Trust Secretary and Mrs Kathryn Ord, Deputy Trust Secretary supported and contributed to the work of the Group.

Appendix 1

Meetings of the group were held between April 2017 and June 2018.

4. Methodology

The review comprised of the following:

 Review of the current routes of involvement for service users and carers within the Trust  Understanding where the ‘gaps’ were around involvement (data taken from Involvement and Engagement Team and appointments to governance groups)  Expert interviews with Recovery Experts by Experience, Service Users, Carers, Directors of Operations and Involvement and Engagement Officers

5. Key Findings and Recommendations

In putting forward the recommendations below to the Council of Governors, if approved the Trust would be required to develop a subsequent action plan which would be monitored via the Council of Governors.

What is classed as involvement?

There are generally considered to be two models involvement: involvement within personal care and treatment and general involvement in the business of the Trust. This review has focussed more on the involvement of service users and carers in the business and provision of services within the Trust.

Recommendation 1

That care and treatment information should be reviewed to better encourage co- production and service user involvement within their own care (eg care plan development) and more awareness given to staff around co-production and what this means in terms of care and treatment.

In respect of personal care and treatment, the group came to the conclusion that there was a range of initiatives within the Trust to take forward the co-production model to enable service users to have a greater say in their own care and treatment.

However, it was found that there was still a long way to go to ensure that everyone’s understanding of this was the same. As the Recovery Programme had not concluded its work and co-production was one of the key deliverables it was felt that at this point in time the only recommendation that could be put forward by the Group was for the strengthening of communication in relation to co-production where referenced in patient care information/leaflets etc.

The Group therefore recommend that all care and treatment related information should be reviewed to ensure that clear, concise information is available to patients. The Recovery programme delivery should better describe how staff can engage with

Appendix 1

patients on a more co-production level and ensure that the service user choice is included within care plans for example. Recommendation 2

To refresh and re-publicise the roles of Recovery Experts by Experience and that of general involvement of service users and carers to allow better signposting and awareness for staff.

Throughout the interview and research process it was very clear to the Group that there was a mixed understanding around terminology with the main area around roles and titles of service users and carers and those that have been trained as a Recovery Expert by Experience. The Group felt that any service user or carer was an expert by experience in their own right and feedback evidenced that they often felt they were lesser valued and did not have the same prestige as those service users who had undertaken the Recovery Expert by Experience Programme.

Research evidenced that staff are confused about which service users should undertake involvement roles and participate in development activity. Often only those service users who had participated in the Recovery Expert by Experience programme are utilised as a first port of call. This results in a negative impact on other service users who have a significant amount of experience and important insightful views to offer.

Not all specialities can be represented by the Recovery Experts by Experience, often resulting in those from Adult Mental Health contributing and participating in roles that are for other client groups eg Older People’s services. It was also noted that the Recovery Experts by Experience roles only have service user representation and no representation of carers.

The research undertaken by the Group showed further roles were being developed in the Trust such as Involvement Peers, Peer Trainers, Lived Experience Roles etc and providing greater clarification on each of the roles and how they should be utilised would help educate staff and give greater clarity as to which route/team to work with to achieve involvement.

The Group therefore felt that strengthening the information available including clarity on each of the roles with examples of what activities these lead on would be beneficial to all involved.

Recommendation 3

To review the inequality of involvement and engagement officer establishment across the Trust.

Appendix 1

Throughout the evidence gathering and discussions it was very clear to the Group that there was a very different way of working and support provided to locality areas and service users and carers within the Trust.

The outlying area was York and Selby who had the benefit of an Involvement and Engagement Officer employed full time. The service provision and impact of this resource was a significant increase in the amount of involvement being undertaken within the locality with significantly more co-production around and engagement around the provision of services, quality improvement and the work to provide a new hospital for the area.

The role has the benefit of being co-located within the management suite of the York and Selby locality which resulted in more dialogue, discussions, planning, sharing of information and advice to ensure more appropriate involvement of service users and carers.

The role also allows more time for the officer to work with, support and develop service users and carers in their involvement journey and lead on the delivery of an involvement group. The Group noted that within the full time resource allocation, the post did also lead on some Trust wide initiatives alongside other members of the Involvement and Engagement Team.

In other localities the allocation of Involvement and Engagement Officer time is 18.45 hours. This time allocation has to support the locality and its staff through organising, advising and supporting involvement of service users and carers as well as recruiting, working with and developing service users and carers to undertake involvement activities. In addition there are lead areas of Trustwide work that each officer undertakes.

The Group therefore recognise that for meaningful involvement within a locality, where its projects, services and staff are truly supported to carry out involvement and for meaningful support, development and mentoring of service users it is recommended that a full time officer is available for each locality.

Recommendation 4

Locality management to strengthen the work they do with their locality involvement and engagement officer (York and Selby locality seen as the exemplar of working).

As referred to under Recommendation 3, there is a significant difference in the integration of Involvement and Engagement Officers within locality management structures and governance.

The evidence has shown that resource available from the Involvement and Engagement Officer is not fully utilised within the localities with the skills, experience and advisory role not fully valued (York and Selby excluded).

Appendix 1

The model of working within York and Selby has shown that where staff within the locality liaise and seek support of the Involvement and Engagement Officer, the experience of the service user/carer is often much improved and better outcomes are seen for the Trust.

If the Involvement and Engagement Officers are aware of key work plans within the locality, better planning can be undertaken to coordinate the involvement of service users and carers and assist in the preparation required to ensure meaningful involvement for both parties.

Recommendation 5

To undertake more awareness raising with staff around what involvement of service users and carers is, what it means and how to undertake it.

The findings of the group confirmed what is already known within the Trust regarding the general confusion of staff as to who to contact when a service user or carer is required to assist with a piece of work.

Recommendation 2 above refers in terms of greater identification of the roles; however it was felt that more work could be undertaken by Involvement and Engagement Officers to help staff understand better about what involvement means, how it can be undertaken and what their own roles are in supporting service users and carers who are working with them.

The Group would like to recommend that, to enable staff to have greater knowledge of the different teams supporting involvement in the Trust work is undertaken by the Involvement and Engagement Officers to link into teams and services and work with staff to raise greater awareness of the Ladder of Participation and how this is applied to involvement

Recommendation 6

To produce and provide a glossary of terminology linked to Quality Improvement which is issued to service users and carers prior to participation.

Through the interviewing process, a number of service users and carers who had been involved in Quality Improvement Processes identified that they struggled with the amount of acronyms used that were linked to the processes.

Appendix 1

When identifying service users and/or carers to participate in any Quality Improvement event, the Group recommend that a glossary is developed and provided prior to the event that would better aid understanding of what is being discussed and in turn enable the person to contribute more meaningfully.

Recommendation 7

For the Trust to review how services utilise social media platforms to engage with service users and carers.

Throughout the evidence gathering process and the experiences the Group felt that the Trust did not utilise the social media platforms available to engage with service users and carers in a way that allowed 2 way dialogue or in a way to seek feedback, views on services.

There is a vast number of Trust service users and carers who are unable to contribute through the standard ways of involvement for a variety of reasons but they still have a voice and an opinion which the Trust should harness more.

This recommendation therefore is to ask the Trust to consider how it could use the power of social media better particular around service re-design, consultations and general engagement.

Recommendation 8

To fund and deliver an annual celebration of involvement to demonstrate how much takes place and to thank those that undertake this work.

The Group identified that there was a significant amount of involvement taking place within the organisation which has shown demonstrable changes in the lives of people undertaking involvement as well as improving the services that the Trust offers.

It was felt that this was not fully known or recognised by the Trust in terms of value but also the recognition to the service users and carers could be improved.

Success has been seen at a previous Volunteer Celebration events and the Group would like to recommend that that the Trust fund an annual celebration to firstly, recognise the range and amount of involvement work that has been undertaken, secondly the difference that this has made to services and thirdly the beneficial impact that involvement has made to people’s lives.

Appendix 1

Conclusion

The Group believe that by undertaking this review they have gained a well-rounded perspective of how the involvement of service users and carers is undertaken and coordinated within the Trust.

It considers that the pragmatic recommendations that have been developed should enable greater support and more meaningful involvement of service users and carers which would not only benefit them but also the staff and services within the Trust.

Valuing the people that undertake involvement work should not be underestimated, it is recognised that involvement payments and reimbursement of expenses are offered but personal recognition and celebration would provide so much more pride and encouragement.

Background Papers

SWOT Analysis (attached Annex 1) Notes of meetings Interviews with staff, service users, carers and Recovery Experts by Experience Supporting papers for meetings

Appendix 1 Annex 1 STRENGTH WEAKNESS Process Process  Large range of involvement activities available  Often insufficient notice given by staff for involvement activities  Involvement Opportunity flyers contain a lot of information that is resulting in poor planning and support and the ability to match the needed to enable service user and carers to self‐select against right person to the right role  Linking involvement to key business priorities demonstrates  Involvement often requested at short notice creating more pressure meaningful involvement and adds value on Involvement and Engagement Officers  Involvement is seen as a business priority within the Trust  Lack of pre information / briefings ‐ lack of preparation results in  Level of training provided to Recovery Experts by Experience is service users and carers not having time to prepare and thus feel welcomed undervalued and tokenistic  Events often cancelled and not communicated well to those that Resource have offered to take part  Having a local contact such as an Involvement and Engagement  Not enough investment in training and support for those Officer is valuable undertaking involvement  Vale of York having a full time Involvement and Engagement Officer  The way service users and carers are involved in recruitment – has aided the amount involvement and the level tpeople ge varying ways and experiences. No clear consistency involved in  Recovery Experts by Experience seen as the group to go to for views,  Where there is an Involvement and Engagement Officer linked into regardless of actual requirements. Ie is a recovery view/approach local management and works in partnership with that management essential – this demonstrates increased involvement in Trust business and  Not all areas have service users or carers involved in governance, major service changes very inconsistent in how appoint to, role undertaken and no clear  Durham has an excellent support network for young people and a support mechanisms carer group for their families  Training / knowledge/ skill base of staff is lacking in some areas  Significant amount of time must be dedicated by Involvement and around involvement and how to support service users and carers in Engagement Officers to support and building networks alongside these activities supporting service users and carers to develop their own experiences in involvement Resource  Part time working of Involvement and Engagement Officers impacts Experience the amount of support that can be provided to services and staff  Those who undertake involvement generally feel valued and also the service users and carers.  Involvement can be life changing for individuals and there are many  Lack of knowledge and awareness of staff around what involvement instances where this can be evidenced of service users should look like, how this can be applied to the Ladder of Participation including what their roles are in supporting General Appendix 1 Annex 1  Having a group of peers (eg Recovery Experts by Experience) is seen Experience as valuable support for those undertaking involvement  Lack of up to date knowledge on the skill mix, interest area of  The Expert by Experience Programme has challenged some of the service users and carers can impact the support provided to them tokenism of involvement that has previously been identified and the activities that they are invited to undertake  Triangle of Care has re‐energised groups of carers  Current methods of involvement do not capture the ‘quiet voice’ or those who struggle to attend meetings. There are other ways to involve service users and carers that are not being explored.

General  Lack of networking peer support for involvement service users and carers compared to the Recovery Expert by Experience programme  Involvement of service users within Durham and Darlington has been difficult to progress within specifically within the locality and business priorities OPPORTUNITY THREAT Process Process  Durham and Darlington locality will be testing out a new model of  Where short notice involvement – obvious last minute thought – involvement in governance – need to await the outcome of this feeling of meaningless and tokenistic to service users and carers  Utilising different methods including social media platforms to  Perception of a tick box exercise from those undertaking gather views and experiences from a wider range of service users involvement and carers and also the ‘quiet voice’  Confusion of roles of Recovery Experts by Experience and  How do the FFT scores be utilised better to inform and enhance involvement and who to contact for what type of involvement involvement of service users and carers required  Utilising quality improvement processes better for involvement Resource Resource  Business as usual for the Recovery Expert by Experience programme  None without funding is challenging  Limited resource of Involvement and Engagement officer support Experience can hinder the amount of involvement coordinated and undertaken.  Service users and carers being involved in inspections provides a This also affects how much support can be given to staff and also vehicle for fresh eyes and allows peoplee to see th changes in the service users and carers services and understand how those who are inpatients to see what  Not being directly linked with the locality management can hinder it is really like the amount of involvement undertaken and the advice and support  There is demonstrable evidence when service users and carers are provided by Involvement and Engagement Officers Appendix 1 Annex 1 involved right from the onset of a process/activity – this can and Experience does impact the quality of services  Strong voices in groups can overpower those less strong  The Trust expects a lot from service users and carers General  Desire to see an annual celebration of work – link to volunteers General  Should extend the Recovery Experts by Experience Programme to  Terminology – Recovery Expert by Experience. Everyone is an other specialities expert in their own right. This can offend some service users  The involvement payments cause individuals problems with DWP especially if they don’t understand their benefits and circumstances  People are out of pocket through involvement for ‘other expenses’ phone calls, printing buying clothes to attend meetings  Impact of payments/benefits and lack of understanding and support  Unless linked to the Trust and know the right people, often people don’t know about involvement activities that people can get involved in  Some people when first get involved it is a personal campaign through personal experience

Council of Governors

Task and Finish Group Scoping Paper

Title of Review: Involvement of Service Users and Carers in TEWV

Governor Catherine Haigh Sponsor Background: Service user and carer involvement within health and social care is a key element of a number of national policies and strategies:

NHS England sets out its “ambition of strengthening participation in all of our work” and pledges to “work in partnership with patients and the public, to improve patient safety, patient experience and health outcomes; supporting people to live healthier lives.”

The NHS Constitution for England, outlines a number of patient rights and responsibilities.

NHS England’s Five Year Forward View advocates involving communities and citizens “directly in decisions about the future of health care services”.

Health and Social Care Act 2012 Within this Trust, there is also a number of Frameworks and Strategies that seek to be inclusive in terms of the involvement and engagement of patients and carers:

 Involvement and Engagement Framework  Recovery Strategy  Research and Development  Draft revised Quality Strategy  Volunteer Strategy  Medical Development and Education  Inspections  Public Membership

TEWV supports the involvement of service users and carers in all of its work and improvement work.

Terms of Taking into account a clear directive that NHS providers should seek to Reference: ‘involve’ its patients and carers the task group should seek to:

1) Research how TEWV seeks to involve service users and carers. 2) Identify any reporting mechanisms of the involvement of service users and carers. 3) Review how service users and carers are selected for involvement activities and where these are drawn from. 4) Review how service users and carers are involved in major

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developments within the Trust. 5) Review how service users and carers are involved in recruitment of staff within the Trust. 6) Review how service users and carers are involved in service improvements within the Trust. 7) Identify and recommend best practice for the meaningful involvement of service users in 3, 4 and 5 above. 8) Recommend appropriate monitoring and reporting processes for the involvement of service users and carers.

Group Trust Secretary Membership: Deputy Trust Secretary / Involvement and Engagement lead Non Executive Director - Chair Governor Sponsor A minimum of four Members of the Council of Governors including a staff governor

Research 1. Explore the different ways service users and carers are involved Methodology: within the Trust. 2. Interview key personnel linked with involved. 3. Understand processes used within other Mental Health Foundation Trusts 4. Understanding the statutory requirement for involvement. 5. Identification of what is meant by meaningful involvement of service users and carers and why it is necessary. 6. Identification of what the Governor role is for the monitoring of involvement of service users and carers 7. Identification of the options for improvement 8. Formulation of preferred options and reporting. Key documents for research (internal and external) https://www.england.nhs.uk/wp-content/uploads/2015/11/ppp- policy.pdf

https://www.gov.uk/government/publications/the-nhs-constitution- for-england

https://www.gov.uk/government/uploads/system/uploads/attachme nt_data/file/213823/dh_117794.pdf

http://www.legislation.gov.uk/ukpga/2012/7/contents/enacted

http://www.nsun.org.uk/about-us/our-work/survivor-researcher- network/

Involvement and Engagement Framework/ Volunteer Strategy

http://www.tewv.nhs.uk/site/get-involved/Being-a-volunteer-patient

http://www.tewv.nhs.uk/site//get-involved/PLACE

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http://www.tewv.nhs.uk/site/get-involved/members/become-a- member

http://www.tewv.nhs.uk/site/get-involved/volunteer

http://www.tewv.nhs.uk/site/get-involved/research-and- development/get-involved

Report commissioned by the Trust on service user involvement within Adult Mental Health for Durham, Darlington and Teesside. (hard copy only)

Budget: Meeting costs of the review can be contained within current budgets.

Resource Four meetings of the Group (3 hours per meeting). Implications: Administrative and research support from the Trust Secretary’s Department (up to 10 days).

Review To be determined by the Group; however, the report and Overview: recommendations of the review to be provided to the Council of Governors for consideration within 18 months.

Expected . A clear understanding as to how the Trust involves service users Outcomes: and carers across its services. . Clear processes to involve service users and carers within the following areas: o Recruitment and selection of staff o Major developments o Process/service improvement

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Item 17

COUNCIL OF GOVERNORS 29th NOVEMBER 2018

EXAMPLE OF A SUMMARY DESCRIPTION OF A TRUST CORPORATE SERVICE - FOR COMMENT

HUMAN RESOURCES AND ORGANISATIONAL DEVELOPMENT DIRECTORATE

Non-medical staff recruitment

The organisation and delivery of job fairs and working with services to design and deliver non-medical staff recruitment campaigns.

TEWV makes over 1,000 appointments each year.

Employee Relations

The provision of advice about terms and conditions of service to individuals, teams and localities.

TEWV employment policy/procedure development, consultation and implementation.

Supporting disciplinary and grievance hearings and processes and managing the Trust disciplinary investigation team.

Supporting services and staff with the management of organisational change including consultation with staff and operating a redeployment service.

Workforce Information

Using the Electronic Staff Record System to produce workforce information reports and to provide advice/support to services about workforce information processing and managing ad hoc workforce information requests.

Publication of the Gender Pay Gap report.

Managing the Trust job evaluation process including panel organisation and training.

Workforce development

The organisation of mandatory and statutory training provision, overseeing utilisation of the apprenticeship levy and providing Positive Approaches to Training (previously known as Management of Violence and Aggression training),

Oversight of operation of the Healthcare Assistant Career Framework and the production and circulation of statutory and mandatory training compliance reports.

Organisational Development

The provision of staff corporate induction, providing support for teams and individuals e.g. facilitating team building days and providing access to mentors.

Leadership and management development programme development and delivery.

Staff Friends and Family Test and Annual Staff Opinion Survey administration and follow up activities for teams with poor results.

Facilitating the Trusts approach to talent management and supporting the Talent Board.

Oversight of the Trust mediation process. .

Staff health and wellbeing

Management of the annual staff flu vaccination campaign.

Provision of the Employee Support Service, managing the Occupational Health Service contract.

Through the Sickness Absence Team providing managers with support for managing long term sickness absence cases.

Organise the Trust Health and Wellbeing Group that produces the Health and Wellbeing Action Plan.

Provision of staff retreats and the pre-retirement programme.

Temporary Staffing Service

The recruitment, training and general management of bank workers (nurses and healthcare assistants).

The daily supply of bank workers to match requests received from wards.

Working with services to provide bank workers with supervision,

Manage the operation of a neutral vendor contract for the supply of agency nurses and healthcare assistants to wards.

Equality, Diversity and Human Rights

The provision of advice and support to individuals and services about equality, diversity and human rights issues.

The management of the translation service contract

Monitoring and implementation of the Workforce Race Equality Standard action plan within TEWV

Equality and diversity policy development and the provision of advice about equality analysis of policies and business cases

The production of equality information for publication as part of meeting TEWVs public sector equality duty.

Voluntary Services

Work with services to identify demand for volunteers and the recruitment of volunteers.

Overseeing the induction and training of volunteers and the provision of on-going volunteer support and advice to managers

The maintenance of a volunteer database

The organisation of volunteer celebration/recognition events

HR&OD Annual Budget - £4, 314,033

HR&OD Whole Time Equivalent workforce – 85.52

The HR&D Directorate is based at Flatts Lane Centre, Normanby, Middlesbrough and at Lanchester Road Hospital, Durham.

ITEM NO. 18

FOR GENERAL RELEASE

COUNCIL OF GOVERNORS

DATE: 29th November 2018

TITLE: Gender Pay Gap Report REPORT OF: Director of Human Resources and Organisational Development REPORT FOR: Information

This report supports the achievement of the following Strategic Goalls:  To provvide excellent services working with the individual users of our services and their families to promote recovery and wellbeing To continuously improve the quality and value of our work  To recruit, develop and retain a skilled, compassionate and motivated  workforce To have effective partnerships with local, national and international organisations for the benefit of the communities we serve To be recognised as an excellent and well governed Foundation Trust that makes best use of its resources for the benefit of the communities we serve. 

Executive Summary:

To share with Governors the findings of analysis undertaken associated with the Gender Pay Gap Report. The Trust were required to publish details on a range of factors linked to the gender pay gap on 5th April 2018. Foollowing the publication of the report it was agreed further analysis would be undertaken to better understand the data being presented. The report at appendix 1 provides the analysis undertaken pertaining to recruiitment to vacancies band 8b and above. The report also provides a summary of a report published by the Government Equalities Office which highlights evidence based actions employers can take to reduce inequalities.

Recommendations:

To note the contents of the report and to comment as appropriate.

MEETING OF: Council of Governors DATE: 29th November 2018

TITLE: Gender Pay Gap

1. INTRODUCTION & PURPOSE:

To report to Governors the findings of analysis undertaken into vacancies band 8b and above recruited to in the 12 month period ending July 2018.

2. BACKGROUND INFORMATION AND CONTEXT:

The Government Equalities Officce have recently published a document called “What Works” guidance which sets out effective actions that employers can take to improve the recruitment and progression of women and close their gender ppay gap.

3. KEY ISSUES:

AAppendix 1 shows the details of the analysis undertaken and proovides a breakdown of issues considered. The report also provides a review of the acttions outlined within the “What Works” guidance.

4. IMPLICATIONS:

4.1 Compliance with the CQC Fundamental Standards:

The report will provide evidencce to support the Trust is strriving to meet the requirements of the CQC Fundamental Standards.

4.2 Financial/Value for Money:

No specific implications have been identified.

4.3 Legal and Constitutional (including the NHS Constitution):

No implications have been identified at this time.

4.4 Equality and Diversity:

The publication of the Gender Pay Gap report enabled the Trust to comply with the requirements of the Equality Act 2010 (Specific Duties and Public Authorities) Regulations 2017.

4.4 Other implications:

No other implications have been iidentified at this time

5. RISKS:

No specific risks have been identtified.

6. CONCLUSIONS:

The gender split by pay band highlights that at band 8b and abovee the proportion of females to males reduces in comparison with the gender split of the organisation. Analysis of band 8b and above vacancies found the following:-

 The analysis of vacancies highlighted bands 8b, 8d and 9 generated a higher proportion of applications from females than males.  Although band 8c and VSM vacancies generated fewer applications from females this did not seem to impact on the ratio of females successfully appointed to the positionss available.  It was interesting to note seventeen out of nineteen appointtments were internal candidates.  The National Staff Survey highlights that 93%of females believed the organisation provides equal opportunities for career progresssion. This appears to back up the analysis undertaken.  Analysis undertaken to better understand any pay differentiials of staff appointed to the same pay band highlighted were attributable to the Aggenda for Change pay structure .

7. RECOMMENDATIONS

To note the contents of the report and to comment as appropriate.

Beverley Vardon-Odonkor Head of HR and Workforce Assurance

Appendix 1

GENDER PAY GAP REPORT ANALYSIS OF BAND 8B AND ABOVE RECRUITMENT EPISODES

1.0 Introduction

The Trust was required to publish information outlining details of any gender pay differences that exist within the organisation. A report was produced based on a snapshot at 31st March 2017. The report was received for considderation by the Trust Board and information published on the Trust website. The information highlighted that the Median Gender Pay Gap within TEWV was 9% i.e. that male employees are paid 9% more on average than female employees. The mean average pay gap was reported as being 14%. An initial analysis of the reason(s) for the pay gap identified that on average male employees have longer service than female employees and that this helped to explain the pay gap, at least in part. Following the publication of the report further analysis has been undertaken to understand the gender breakdown of applicants to vacancies at band 8b and above. The analysis further considered the gender brreakdown by shortlisting and appointment to the vacancy.

2.0 Analysis

Following the publication of the Gender Pay Gap report further analysis was undertaken and presented to the Trust Board. The chart below highlights the gender breakdown by pay band. The chart highlights that up to band 8b and above the gender split bby band is comparable to the overall Trust gender split. Gender Breakdown by Pay band

1200%

1000%

80%

60%

40%

20%

00% Band Band 9 Medical 2& HCA Other Trust Band 1 Band 3Band 4 Band 5Band 6 Band 7Band 8aBand 8b Band 8c Band 8d & Exec Consult framew Medics pay ant ork Male 23% 7% 21% 23% 17% 20% 21% 23% 22% 31% 33% 43% 57%56%38% Female 77% 93% 79% 77% 83% 80% 79% 77% 78% 69% 67% 57% 43%42%62%

The following tables highlight the findings from the analysis undertaken. The first table shows the breakdown of all band 8b and above vacancies analysed. A tottal of nineteen vacancies were analysed. Seventeen of the successful candidates were internal.

All vacancies 8b Applications for and above vacancies Shortlisted Successful applicant Gender split Female Male Female Male Female Male Number 55 47 43 25 10 7 % 54% 46% 63% 37% 59% 41%

The table below is band 8b and shows the application, shortlisting and successful applicant gender breakdown to be comparable to the gender breakdown of the current band 8b workforce. A total of ten vacancies weree analysed, eight successful applicants were internal and two external.

Band 8b Applications for vacancies vacancies Shortlisted Successful applicant Gender split Female Male Female Male Female Male Number 33 17 26 11 6 4 % 66% 33% 70% 30% 60% 40%

The table below is band 8c and shows whilst there were less female applicants for the four vacancies advertised 50% of the successful candidates were female. Thrreee of the posts were full time and one was part time. Two were fixed term. Three posts were Consultant Applied Psychologist vacancies. All of the successful applicants were internal candidates.

Band 8c Applications for vacancies vacancies Shortlisted Successful applicant Gender split Female Male Female Male Female Male Number 7 11 6 8 2 2 % 39% 61% 43% 57% 50% 50%

The table below is band 8d vacancies, there was one recruitment episodee for two vacancies which resulted in no appointments being made. The posts were Professional Lead Psychologists. The posts have recently bbeen re-advertised and at the time of the production of the report we are awaiting notification as to whether an appointment has been made. The posts are part time positions.

Band 8d Applications for vacancies vacancies Shortlisted Successful applicant Gender split Female Male Female Male Female Male Number 7 2 7 0 0 0 % 78% 22% 100% 0% 0% 0%

The table below relates to one vacancy band 9, the successful applicant was an internal candidate.

Applications for Band 9 vacancies vacancies Shortlisted Successful applicant Gender split Female Male Female Male Female Male Number 5 3 2 0 1 0 % 63% 37% 100% 0% 100% 0%

The tablle below relates to Very Senior Manager vacancies, of which there were two during the reporting period. The successful applicants were both internal. The gender breakdown of applicants is not reflective of the gender breakdown of the current band 9 and VSM workforce. The successful applicant gender breakdown is comparable to the workforce gender profile.

Applications for VSM vacancies vacancies Shortlisted Successful applicant Gender split Female Male Female Male Female Male Number 3 14 2 6 1 1 % 18% 82% 25% 75% 50% 50%

The 2017 National NHS Staff Survey reports tthat 93% of females (2330) believed the organisation provided equal opportunities for career progression. Over recent years the Truust has invested in the development of a new appraisal system which includes the opportunity to participate in a talent management conversation. The focus of the talent management conversation is to allow individuals to spend protected time considering how they would like their career to develop and also highlights any personal development needs the individual may have. The information is heeld centrally and helps the organisation to effectively manage succession planning. 93% of femalle respondents to the survey indicated they had participated in an appraisal in the preceding 12 months.

Analysis has previously been undertaken to try to understand differences in pay for those staff employed on Agenda for Change terms and conditions. This involved a random sample of female and male pay for each band being undertaken and the reasons for the difference was determined to be attributable to the length of time in post in line with the incremental pay systtem.

Further analysis has been undertaken linkedd to the recruitment episodes highlighted above. The analysis involved reviewing the AfC pay band and increment point prior to moving in to the new post and the current pay point in the new post. The analysis involved applying the rules outlined in the AfC handbook on pay progression on appointment to a new post. A review of all of the salary entry points for appointments to bands 8b and 8c was undertaken. All of the current salary entry points were in line with the AfC incremental progression rules outlined within the AfC handbook. Differentials identified were attributable to AfC pay system eg the successful candidate was already on the pay band prior to moving into post, or at the top of their current salary band and so on promotiion progressed up the pay scale, or moved on to the minimum of the salary scale.

3.0 Government Equalities Office Guidance

The Government recently announced 100% of relevant employers had published their gender pay gap data. The Government Equalities Office have subsequently produced guidance called “What Works” which outlines effective actions employers can take to improve the recruitment and progression of women and close the gender pay gap. The following are recommended as evidence based:‐

 Include multiple women in shortlistts for recruitment and promotion. When putting together a shortlist of qualified candidates make sure more than one woman is included. Shortlists with only one woman do not increase the chance of a woman being selected.  Use skill based assessment tasks inn recruitment. Rather than relying only on interviews, ask candidates to perform tasks they would be expected to perform in the role they are applying for.  Use structured interviews for recruitment and promotions. Structured and unstructured interviews both have strengths and weaknesses, but unstructured interviews are more likely to allow unfair bias to creep in and influence decisions.  Encourage salary negotiation by shhowing salary ranges. Women are less likely to negotiate their pay. This is partly because women are put off if they are not sure about what a reasonable offer is. Employers should clearly communicate the salary range on offer for a role to encourage women to negotiate their salary. If the salary for a roole is negotiable employers should state this clearly as this can also encourage women to negotiate. If women negotiate their salaries they will end up with salaries that more closely match the salaries of men. If the salary for a role is negotiable, employers should state this clearly.  Introduce transparency to promotion, pay and reward processes. Transparency means being open about processes, policies and criteria for decision‐making. This means employees are clear what is involveed and that managers understand that their decisions need to be objective and evidence‐based because those decision can be reviewed by others. Introducing transparency to promotion, pay and reward processes can reduce pay inequalities.  Appoint diversity managers and/or diversity task forces. Diversity managers and task forces monitor talent management processes (such as recruitment or promotions) and diversity within the organisation. They can reduce biased decisions in reecruitment and promotion because people who make decisions know that their decision may be reviewed.

The guidance also includes a range of actions which require further research, a copy of the guidance is available at https://gender‐pay‐gap.service.gov.uk/public/assets/pdf/Evidence‐based actions for employers.pdf.

4.0 Conclusions

The gender split by pay band highlights that at band 8b and above the proportion of females to males reduces in comparison with the gender split of the organisation. The analysis of vacancies highlighted bands 8b, 8d and 9 generated a higher proportion of applications from females than males. Although band 8c aand VSM vacancies generated feewwer applications from females this did not seem to impact on the ratio of females successfully appointed to the positions available. It was interesting to note seventeen out of nineteen appointments were internal candidates. The National Staff Survey highlights that 93%off females believed the organisation provides equal opportunities for career progression. This appears to back up the analysis undertaken. Analysis undertaken to better understand any pay differentials of staff appointed to the same band highlighted were attributable to the Agenda for Change pay structure.